Archive for February, 2009

Does Botox treat migraines and wrinkles at the same time?

Tuesday, February 17th, 2009

When treating chronic daily headache or migraines with Botox, most doctors will use a modified “Follow the Pain” approach.  Simply stated, that means if your migraines start out as tension in the middle of your forehead and between the eyes, then these are the areas that will receive some Botox. Treating these areas will also help upper face wrinkles. 

However, if your headaches normally start in the occipital area (back of the head) or temporal area (side of the head), then there may not be any clinical justification for putting Botox in those muscles of the upper face.

Due to the fact that these specific muscles (which cause the wrinkles in the upper face) are not being treated, you should not expect to see any improvement in those wrinkles.

Can Botox treat hyperhidrosis?

Tuesday, February 17th, 2009

Botox is extremely effective for Hyperhidrosis.  According to a study published in The Journal of Drugs and Dermatology this year that compared Aluminum Chloride deodorants (Drysol) to Botox, patients had 92% satisfaction with Botox vs. only 29% with the Aluminum Chloride deodorant after 4 weeks. 

Injections done by a qualified practictioner cause minimal discomfort and effects normally last about 3-6 months.

Can I get imported Botox Cosmetic for a lower cost?

Tuesday, February 17th, 2009

Unfortunately the answer is very much no.  Your friend’s doctor is doing something both unethical and illegal. 

The DEA makes it illegal to import Botox or any other injectable from another country because they cannot monitor the product.  The other issue is that of counterfeiting, which has become big business around the globe.  This is especially true of Botox coming from Canada, Mexico, and France. 

  • The only way to assure yourself that you are getting the real thing is to copy down the lot number and call Allergan (the manufacturer of Botox) to double check that that particular lot number was delivered that the doctor who injected it. 
  • Another tip, make sure that your provider is willing to mix the Botox in front of you (it comes as a dry powder) that way you are assured they are not over-diluting their product.

Should I buy Botox by the CC or by units?

Tuesday, February 17th, 2009

A vial of Botox cost all physicians about the same and contains 100 units of Botox. The vial comes as a dry power which is reconstituted with sterile saline. Different providers use different amounts of saline. This is usually anywhere from 1-4ccs. This means you could be getting anywhere from 25 to 100 units of Botox per cc if you paying buy the cc.

Studies suggest that the higher potencies (i.e. less dilute) of either 1-2ccs tend to work the best.  Botox should normally cost between $10 – $18 per unit, depending on the injector.  Any less and the Botox is most likely from outside the country which is both illegal (The FDA cannot monitor it) and highly suspect for counterfeit.  If you buy it by the unit, you understand exactly how much your provider is using over which areas and make sure you get a fair price.

Best alternative to laser hair removal for dark skin?

Tuesday, February 17th, 2009

If you have fairly dark hair the simple answer is a 1064nm Nd:YAG laser (Cynosure Elite, Candela Gentle YAG and Cutera Coolglide).  As long as the hair is darker than the skin you should be able to treat it with no problem.  If there is little difference between hair and skin pigment then a test spot is usually in order.

As mentioned before the Nd:YAG laser may take a few more treatments (8-10) to really clean an area up well.  This is because it has less absorption in melanin (the pigment than gives both skin and hair their color).  Because it has less absorption it will not damage darker skin but it also does not provide as much heat to the hair shaft which is why it generally takes more treatments. 

If your skin is a type IV (Hispanic or Asian) you may also be able to use and 810nm Diode laser such as the Lumenis Light Sheer.  Diode laser fit in between the super high absorption 755nm Alexandrite and the moderate absorption of a 1064nm Nd:YAG.  They are a good balance of safety and effectiveness in patients with moderate pigmentation.  Either way you are likely a good candidate for hair removal it will just require the right tool for the procedure.

Juvederm – what are these white bumps around my lips?

Tuesday, February 17th, 2009

If Juvederm is placed incorrectly, it will normally shows up as bumps or slightly bluish skin discoloration.   If the bumps are less than 1mm and white, they are likely sebaceous glands. These are normally present on the vermillion (pink part of the lip) border especially on the upper lip.  Usually they are 1mm or less in size and white to yellow in color. 

 Sebaceous glands make the oil for our skin and occasionally get blocked.  It is unlikely that these blocked glands were caused by the Juvederm.  They can be removed with aggressive microderm, TCA acid peals or very minor surgery.

Slim lipo vs. Smartlipo: which is best?

Tuesday, February 17th, 2009

The new SmartLipo MPX has two wavelengths (1064nm and 1320nm) vs. the Slim Lipo (920nm).  Although Palomars 920nm Slim Lipo may look like a good wavelength for fat on paper it actually may not work as well.  The reason is that the target is actually the membrane around the fat (a mixture of both water and lipid) and not the fat itself.  When we hit the membrane with the right wavelength the fat cell breaks apart.  The contents of the broken fat cell are either aspirated during the last part of the procedure or are broken down and removed by the immune system.  Barry DiBernardo in New York did some nice work showing these broken down contents did not increase the level of fats in the blood stream and therefore it is very unlikely that any remnants missed by aspiration are remanufactured into functional fat cells.

Due to power and the size of the laser fiber, the SmartLipo MPX is able to cut through more fat in less time than the SlimLipo.  A head to head clinical study would be extremely beneficial to sort out the actual differences between the two devices.  All in all both machines can be used effectively for fat reduction but the SmartLipo has had much more peer reviewed research and thus is understood better.

LAL (laser assisted lipo) has some significant advantages over other types of lipo. When comparing to traditional lipo with a 4-6mm cannula, there tends to be less damage to the connective tissue with LAL.  This is probably due to the smaller cannula size with LAL.  Although it is somewhat provider dependent, the LAL devices tend to cause less swelling, less bruising and thus less downtime likely due to the fact that they coagulate blood vessels during the procedure.  Also, to date there have been no reported cases of superficial vascular changes (unlike with traditional superficial liposuction and ultrasound assisted lipo).

Which laser skin treatment is best for acne scars?

Tuesday, February 17th, 2009

There are so many entities out there claiming efficacy for treating acne scarring that it can become very confusing. These range from non ablative light based therapies such as Laser Genesis and Pulsed Dye Laser to fully ablative CO2 resurfacing. The Active FX combined with the Deep FX tend to offer the best combination of results, side effects and downtime.

In our experience non-ablative lasers, such as Laser Genesis, will max out at about 30-40 percent improvement with a minimum of five treatments. The best results may require upwards of 8-10 treatments. Most patients favor these procedures for treatment of enlarged pores or fine lines and not necessarily acne scars.

On the other end, CO2 laser is the gold standard for results. There are a few downsides to full CO2 resurfacing. These include downtime, which can last several weeks with the possibility of having several months of residual redness. Discomfort and swelling may also last several weeks. Long term side effects such has permanent hypopigmentation (lightening of the skin) and scaring have been significantly reduced but still occur. Due mostly to the significant downtime, full CO2 resurfacing tends to not be the treatment of choice.

For most patients the best options are the fractionated lasers. These include things like Active FX, Deep FX and Fraxel Repair which are all form of ablative CO2 lasers. When treating with a fractionated laser, there are patches of skin that are not affected by the laser. The amount of skin treated vs. untreated can be controlled by your provider. These patches of untreated skin drastically reduce both side effects and downtime. Even though these procedures have mostly eliminated side effects such as skin discoloration and scarring they still produce about 80-90% of the effects that are achieved with full CO2.

I am not as much of a fan of the Fraxel Restore (non-ablative Erbium) because, although it has been proven to improve acne scars, it takes a minimum of 5 treatments and produces less results than 1 -2 treatments of the fractionated CO2 devices (Active FX, Deep FX and Fraxel Repair).

Between the Active FX, Deep FX and Fraxel Repair, I like the combination of Active FX and Deep FX better because the technology is less provider dependent and there are some engineering advantages to the Active and Deep FX.  There was a head to head study performed at Johns Hopkins in 2008 where patients had one side of the face treated with the Active FX and the other side was treated with Fraxel Repair.  Nine out ten people preferred both the procedure and the results of Active FX side.

No matter what your providers tells you expect 2-3 treatment with a minimum of 30-90 days between treatments for the best results.

What's the best way to tighten loose skin?

Tuesday, February 17th, 2009

There are several “Skin Tightening” devices, and none are created equally.  The two main categories are:

  1. Ablative (vaporized some elements of the skin)
  2. Non-ablative.  

The non ablative procedures have little to no downtime and tend to cost a little less per procedure while the ablative procedure tend to provide better results but can have significant down time.

Ablative: higher cost, better results, more downtime, usually single treatment

CO2
The ”gold standard” of tissue tightening is full CO2 resurfacing.  This procedure ablates 100% of skin over the treated area.  It can range in cost from $5000-$15000 dollars and usually requires at least two weeks of downtime but usually more.  Results are normally significant and last several years.  Redness after the procedure can last months and other side effects can include permanent lightening of the skin and or scaring.

Fractionated CO2
Fractionated procedures, such as Active/DeepFX and CO2 Fraxel, normally ablate anywhere from 20-80% of the skin by punching holes about twice the diameter of a human hair into the skin.  These procedures offer many of the tightening benefits of full CO2 with less downtime, cost and risk of long term side effects.  

Although I am not aware of any head to head studies that specifically address skin tightening between full CO2 and fractioned CO2, I can say that during an Active/Deep FX procedure a provider can actually watch the skin tighten as the laser passes over the treatment area. 

Cost is about $2500-$4000.  Expect anywhere from 5 day to 2 weeks of downtime with fractionated CO2 depending on how aggressively your provider performs the treatment. The procedure provides excellent results that last several years.

Non-Ablative: Lower cost, little or no downtime, less results, usually a series of treatments

Titan
Infrared light used to heat collagen so it shrinks and simulated new collagen growth over a 3-6 month period.  I have used this machine since 2004 and works well for laxity around the eyes, cheeks and neck, so-so for jowls. 

Procedure cost about $800-$1000 for a full face. There is no downtime but plan on at least three procedures.  Results usually last about 18 months, and about 80-85% of patients are happy with results. This is a very tolerable procedure, and the side effects are limited to a very rare blister.  

The LuxIR also uses infrared light to treat skin laxity, but there seems to be slightly less consistency in the literature with this devise.

Thermage
Uses Radiofrequency to heat tissue.  Although I have seen this machine be effective the reports in the literature say that it only works well about 29% of the time. 

The treatments can be very painful and in rare cases radiofrequency can cause damage to the fat layer under the skin resulting in loss of volume over that area.  Cost range from $1000-$3500 and plan on 1-3 procedures with little to no downtime.

What’s the best way to tighten loose skin?

Tuesday, February 17th, 2009

There are several “Skin Tightening” devices, and none are created equally.  The two main categories are:

  1. Ablative (vaporized some elements of the skin)
  2. Non-ablative.  

The non ablative procedures have little to no downtime and tend to cost a little less per procedure while the ablative procedure tend to provide better results but can have significant down time.

Ablative: higher cost, better results, more downtime, usually single treatment

CO2
The ”gold standard” of tissue tightening is full CO2 resurfacing.  This procedure ablates 100% of skin over the treated area.  It can range in cost from $5000-$15000 dollars and usually requires at least two weeks of downtime but usually more.  Results are normally significant and last several years.  Redness after the procedure can last months and other side effects can include permanent lightening of the skin and or scaring.

Fractionated CO2
Fractionated procedures, such as Active/DeepFX and CO2 Fraxel, normally ablate anywhere from 20-80% of the skin by punching holes about twice the diameter of a human hair into the skin.  These procedures offer many of the tightening benefits of full CO2 with less downtime, cost and risk of long term side effects.  

Although I am not aware of any head to head studies that specifically address skin tightening between full CO2 and fractioned CO2, I can say that during an Active/Deep FX procedure a provider can actually watch the skin tighten as the laser passes over the treatment area. 

Cost is about $2500-$4000.  Expect anywhere from 5 day to 2 weeks of downtime with fractionated CO2 depending on how aggressively your provider performs the treatment. The procedure provides excellent results that last several years.

Non-Ablative: Lower cost, little or no downtime, less results, usually a series of treatments

Titan
Infrared light used to heat collagen so it shrinks and simulated new collagen growth over a 3-6 month period.  I have used this machine since 2004 and works well for laxity around the eyes, cheeks and neck, so-so for jowls. 

Procedure cost about $800-$1000 for a full face. There is no downtime but plan on at least three procedures.  Results usually last about 18 months, and about 80-85% of patients are happy with results. This is a very tolerable procedure, and the side effects are limited to a very rare blister.  

The LuxIR also uses infrared light to treat skin laxity, but there seems to be slightly less consistency in the literature with this devise.

Thermage
Uses Radiofrequency to heat tissue.  Although I have seen this machine be effective the reports in the literature say that it only works well about 29% of the time. 

The treatments can be very painful and in rare cases radiofrequency can cause damage to the fat layer under the skin resulting in loss of volume over that area.  Cost range from $1000-$3500 and plan on 1-3 procedures with little to no downtime.