Denver Acne Scar Treatment

Many of our patients have come to us very frustrated with the previous information or treatments they have received for their acne scarring.  There are many treatments being promoted for acne scars a few which can be effective and many that are not.  Today I am going to talk a little about the physiology of acne scarring and which treatments are most likely to be effective.

Acne scarring results when the healing process after an acne infection goes array.  After the skin is inflamed by the acne lesion fibrosis can occur.  This is made worse when patient repeatedly pick or squeeze their lesions.  Picking causes repeated trauma and increased inflammation while squeezing can drive infectious material deep into the wound again causing more inflammation.  Fibrotic repair of the lesions lead to the textural changes associated with acne scarring. 
Anatomy of Acne Scarring:
The main thing to understand is that acne scarring lesions tend to be very deep in the skin.  To give an idea of scale, most human hairs are about 100-200 microns thick.  Acne lesions normally extend between 800-2000 microns (.8mm-2mm) into the skin.  This fact alone explains why most acne scar treatment are minimally effective.

Solutions to Acne Scarring:
The most obvious solution to acne scarring is prevention.  Scarring develops during the inflammatory and healing stages of the lesion so there are a couple of ways to prevent it.  First is to keep acne, especially cystic acne under control.  This involves a visit to the doctor and normally some type of education and prescription topical or oral medication.  TV infomercials are not a replacement for a visit to your physician. There are many patients whose acne goes from very controllable to fairly severe because they try months or years of over the counter treatment options that never quite work.  The second part is simply not to pick or squeeze acne lesions.  Picking and squeezing are both inflammatory and make lesions worse.

Acne Treatment Options:
Tretinoin (Retin-A) is one of the very few topicals that has been shown to improving the appearance of acne scarring in peer reviewed clinical trials.  Patients should be very suspicious of any product claims that do not compare their product to either a placebo or Tretinoin. 

Microderm and Superficial Chemical Peels:
Mild fruit acid peels such as Glycolic, Lactic, Salicylic and microderm are often offered up as treatments for acne scarring.  Most of these treatments penetrate from 10-30 microns into the skin, remember acne scarring normally goes from about 800-2000 micros into the skin.  That means even at their best, these treatments only effect the top 5% of the scar.  With multiple repeated treatments this can be slightly increased but even after 10-20 treatments with these modalities there are only modest results at best.

Deeper Peels:
TCA, multiple layer Jessner ‘s Solution can penetrate through the epidermis over 100 micros into the skin.  These products use a chemical reaction to literally burn a thin layer of skin off.  The deeper the lesion caused by the peel, the longer the downtime will be. Peels that do deep enough to completely remove the epidermis will normally take about 7-10 day to recover from but still will only treat about the top 10-20% of an acne scar.  Phenol peels are very deep peels which although they can get moderate results are not used very often any more do to their potential for scarring.
Non Ablative Lasers:
This a large category which includes any light based technology that heats the skin to stimulate collagen synthesis which helps fill in depressions in the skin.  The heat also helps rearrange the abnormal architecture of collagen fibrils that are already present.  Light sources such as Cutera’s Laser Genesis and the Fraxil Re:store fall into this category.  With all of the light sources the energy of the laser is absorbed by water in the tissue and turned into heat.  These procedures require multiple treatment but can provide moderate results with little to no downtime.

Shallow Ablative Lasers:
An ablative laser actually vaporizes (destroys) an area of tissue.  The shallow lasers are normally Erbium devices such the Cutera Pearl and Sciton Contour or Profactional.  These lasers come in versions that treat the entirety of the skin and in fractional versions which only treat a small portion of the skin (like aerating a lawn).  The advantage of the fractional devises is that they tend to go deeper which treats deeper pathology and significantly decrease both heeling time and side effects.  Erbium lasers will tend to product about 30-150 microns of ablations in the full forms and about 600-800 microns in their fractional forms.   The fractional version of these lasers can provide nice improvement in acne scarring but have two draw backs.  The first is that even the fractional versions of Erbium lasers to not get to base of most acne scars and second is these lasers do not provide as much heat to tissue as a CO2.  This heat is necessary to induce remodeling of the tissue that is not ablated and is a major factor in the final outcome that a patient sees in the mirror.

Deep Ablative Devices:
Almost all of the lasers currently in this category are CO2 lasers.  This is the gold standard in revising acne scarring.  The newest devices are fractionated like their more shallow counterparts.  There are many devices in this category including, Pixel, Affirm, Dot, Fraxil Re:pair and Lumenis Active and Deep FX.  Unfortunately most of them are grossly underpowered.    Underpowered lasers need to use very long laser pulses to get the same amount of energy into the tissue as  a short pulse with a properly powered laser.  These long pulses can lead to excessive tissue heating and side effects such as discoloration and even scarring.  These underpowered devices are cheap to build and more affordable to purchase so they have become very common in the medi-spa industry.  I will only go into detail about the appropriately powered devices such as the Lumenis Active FX, Deep FX and Fraxil Re:pair.  These devices can penetrate 2000 microns into the skin or more and thus are the only devices that can reach the entire scar region.  Although good results can be obtain with both devices the clear  king of the mountain is the Lumenis laser.  In a study done a Johns Hopkins 9 out 10 patient preferred both the procedure and results from the Active FX when compared to the Fraxil Re:pair.
Other Treatments:
There are many other treatments including subcision, needling, punching out lesions and adding filler that can all be used to improve the texture of acne scarring.  Although these modalities can be effective, they tend to be more useful for less extensive lesions.

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Denver Latisse Discounts

After 6 months of use we have been receiving ravereviews from Latisse.  This is only FDA product approved for longer, darker and thicker lashes.  These kits are normally $120 but we have teamed up with the manufacturer to offer these kits at $88 for a short period of time.  This discount won’t last long so drop by our office soon to try Latisse for yourself.

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Discounts on Botox and Dysport in Denver, Colorado

Let the marketing wars begin!  Botox throw the first shot at their new competitor Dysport by offering a $50 rebate on any Botox procedure over $200.  Now Dysport has answered with their own rebate of $75 off.  Neither manufacturer seems willing to actually lower the price of their product but this is at least a step in the right direction. 

Now Allergan, the manufacturer of Botox, has fired another shot with the unveiling a new program called Brilliant Distictions.  This new program allows certain offices to give additional rebates to patients.  After every Botox treatment an enrolled patient will receive 200 points into their account.  Every 200 points can be redeemed for a $25 coupon that is good for Botox, Juvederm or even Latisse.  Patient need only enroll in the program on the Brilliant Distinctions home page.

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Skin Tightening and Wrinkle Removal In Denver, Colorado

The most common questions asked in my office are about skin tightening and wrinkle removal.  Patients want to know which laser treatments work the best.  There are so many technologies out there that it is easy to get lost in technical jargon and marketing build up.  The good news is that there are some truly excellent lasers procedures out there for both wrinkle reduction and skin tightening.  The better news is that there are some easy ways to evaluate these technologies.

To truly reduce facial lines is a difficult task, especially wrinkles around the mouth and eyes.  These lines can extend over a millimeter deep into the skin.  It is the depth of the damage that makes them very difficult to treat.  Most procedures for treating wrinkles are very superficial and although they may improve fine lines, they never treat the base of deep wrinkles.  In order to really get improvement one must have a procedure that treated then entire area of damage.  This is why fractionated CO2 procedures like the Deep FX are so effective.  This laser can penetrate up to 2mm into the skin assuring that even deep wrinkles will show significant improvement.  Yes, there will be a few days of downtime but we spent several decades making these wrinkles and a few days is well worth it in order to make the skin look literally years younger. 

What about tightening the skin?  There are two options here depending on the desired amount of improvement and amount of downtime a patient is willing to undergo.  The first option is using an infrared light call the Titan to heat the dermal skin which shrinks the existing collagen (much like a piece of meat shrinks on the grill when heated) and will stimulate new collagen growth.  The dermis of the skin thickens giving modest results of about 10 – 20% tightening after three treatments.  Plan on spending about $600-$1000 per treatment for a face and the results will last about 18-24 months.  The best part about the Titan is that there is absolutely no downtime.  The skin is pink for about 30 minutes after the procedure and that is it. Use this in combination with Laser Genesis which is another no downtime laser treatment that helps decrease pores and fine lines.

The other option is using a combination of Deep FX and Active FX.  A surgical facelift removes approximately 10 to 20 square cm of tissue.  Using fractionated lasers we poke microscopic holes in skin much like aerating a lawn.  After poking these holes, we have removed anywhere from 5  to 10 square cm of tissue.  That means that we can get results that are on par with a facelift without the cost or downtime of a traditional surgery.  This is the reason that many patient are choosing this procedure instead of a facelift (Denver Magazine: Death of the Facelift).  In addition to being the best wrinkle treatment and skin tightening treatment, the combination of Active FX and Deep FX will also treat enlarged pores, sun damage spot and even decrease scars.

There is a ton of confusing marketing when it comes to devices for wrinkle treatment and skin tightening.  With so many products such as Fraxel, Pixel, Matrix, Profractional, Thermage, Lux IR and more being added daily it is hard to know which one is the best.  So how does a consumer rate the different laser procedures?  It is actually very simple, just look at the pictures.  Make sure these are not the generalized pictures from the manufacturer.  Patients should stand firm and request pictures from the provider that will be performing the service.  Ask the provider if these are average results or if they are just showing their “homerun” cases.   If they cannot provide you pictures it is time to find a new provider or look at a different procedure.  Check out examples of before and after photos of Active FX  and Deep FX here.  

It is important that you both trust your provider and the technology they are using.  It takes several hundred cases to optimize clinical outcomes with any devise so make sure to choose someone who can prove that they achieve excellent, safe and consistent results.

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Food Drive with Food Bank of the Rockies

This year in order to give back the Colorado Center for Photomedicine has teamed up with Food Bank of the Rockies to help combat hunger in Denver!  From November 1st through December 31st get a dollar off your service for every single item you bring in up to 50 items.  Simply drop the items off at the office between those dates and we will give you a discount on your services that day or even will add a credit to your account for a future service!

The Food Bank will take any non-perishable food item.  Products such as tuna, ham, beef stew, chili, baked beans, soup, vegetables, fruit, peanut butter, jelly and pasta tend to be the most in demand.  Please take the time to give back this season and we will make it worth your while!

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Zerona versus SmartLipo versus Liposuction Do They Work?

I have had many question about the Zerona body contouring system and if it works.  The premise of this device is to use low level light therapy to get your body to dissolve fat.  This means using power level equivalent to a laser pointer on the skin and expecting that this will remove fat.  I have to agree that a no downtime, completely non invasive liposuction procedure does sounds great, but unfortunately it just does not work. 

I recent returned from a Laser Therapy meeting a Harvard and had a discussion with several of my colleagues about the subject.  These are guys from Harvard, MIT and UC Davis who are much smarter than myself when it comes to understand the engineering behind these devices.  The simple fact is that this device will not penetrate much deeper than 1cm into the tissue.  It defies the laws of light based physics with the energy and type of power source they are using. 

After reviewing the data on their site there are a few things to keep in mind.  First is that circumferential body measurements (literally taking a measuring tape around the body part in question) are notoriously inaccurate.  Simply adding a little more force on the measuring tape can decrease the measurement several inches.   If Zerona really wanted to measure fat loss in an area they needed to do an MRI.  The second is that their own data show the device does not penetrate more that about 1 cm.  The total girth loss in their study was a little over an inch (or about 1cm from both sides).  The slides they show with the fat breaking up are realistic but remember that this is very superficial.  Most fat pads in the body are from 6 to 10 cm thick for people who are not overweight.  For those that are overweight or obese the Zerona device is truly useless.   

So then how does this compare to SmartLipo and traditional Liposuction?  It truth is that it does not compare.  The pictures I have seen on Zerona’s e websites are less than impressive.  They have large lighting and positioning changes.  Even with those camera tricks, they do not show much improvement at all.  My patient would be asking for their money back if I provided them with those type of results.  I have seen other Zerona before and after pictures floating around the web that show amazing results. Those are either altered with Photoshop or they are the results of a different procedure. 

SmartLipo and traditional liposuction are still the standard of care.  We have now performed well over 100 SmartLipo cases and the SmartLipo procedure really does have much shorter downtime than traditional liposuction.  There is much less bleeding which leads to less bruising and swelling.  The lower cost and safety of the SmartLipo procedure also make it very attractive.  A study presented at the American Society for Laser Medicine and Surgery last year showed that SmartLipo produced about twice as much tightening when compared to traditional liposuction. The SmartLipo procedure will take slightly longer to do and is best for those with body masses indexes below about 30.   Overall, given two good surgeons that perform the procedures well, the final results of SmartLipo and traditional lipo are about equal but the SmartLipo will cost a bit less and achieve faster results.

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How Long Does Dysport Last, Is It Cheaper than Botox?

What is Dysport?

Dysport is an injectable protein that was approved by the FDA in April of 2009. It works much like Botox in order to relax facial wrinkles. Like Botox it can also be used to help with excessive sweating (hyperhidrosis) and muscle spasm.

How much do I need?

Although Botox and Dysport are two different products the approximate conversion is around 2.5 units of Dysport for every one unit of Botox. If for instance you normally use 20 units of Botox to treat the wrinkles between the eyes you would need about 50 units of Dysport.

Does Dysport Last Longer Than Botox?

It depends on how many units you use. There are some studies that show Dysport lasting slightly longer than Botox but in most of the those studies a larger ratio than 2.5:1 (Dysport:Botox) was used. When comparing 50 units of Dysport to 20 units of Botox most studies show that their duration of effect is almost identical.

Does Dysport Work Faster Than Botox?

For a small percentage of patients the answer is likely yes. In studies about 35% of patients noticed that their Dysport started working within the first 48 hours.

Does Dysport Cost Less Than Botox?

It depends on how much you use. If you use the equivalent dosing the cost of Dysport is almost exactly the same as Botox.

Is Dysport Safe?

Yes, Dysport has been used in Europe for many years and has an almost identical side effect profile to that of Botox.

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Botox versus Dysport: What is the Difference

With the approval of Dysport by the FDA on April 30, of this year the question on most people’s mind is, “What are the differences between Botox and Dysport?”  There is huge amount of both ambiguous and outright inaccurate information on the web about both of these products.  The main questions are:

  1. Which one works faster?
  2. Which lasts longer?
  3. Are there different techniques needed to do the procedure well?
  4. Are there any safety issues?
  5. Which one is one is a better value?

1.)   In most patients Botox takes about 3 days to start working but in some patients can take up to two weeks to achieve full effect.  Faster onset was noted in about 30% of patients who used Dysport with some seeing effects in as little as a single day.

2.)   Most studies on Botox show that it lasts about 3 to 4 months and there is a direct correlation between the amount of product used and the duration of effects.  Many posts and websites assert that Dysport lasts longer and some studies do indicate a slightly longer duration of effect, but not all of them. In fact some clinical trials indicate exactly the opposite, that Botox last longer.   Clinical experience in the U.S. over the next several months will help guide consensus on this.  For providers who follow the current injection guidelines, expect either product to last about 3-4 months.

3.)  Both dosage and injection technique are product dependent.  The conversion is approximately 2.5 Dysport units to 1 Botox unit, but there is some variation between the upper and lower face.  Another technical issue is that Dysport seems to spread more during injections in most studies.  This can be both a good and a bad thing.  It is good in that large areas that need injection (forehead, armpits) would require fewer injections due to the spreading.  However, it can also be a bad thing if the physician is an inexperienced injector and does not have a good understanding of more complex musculature (around the eyes, between the eyebrows).  In these cases the Dysport could spread into unwanted areas causing untoward side effects such as droopy eyelids and brows.

4.)  Botox has been used for over 20 years starting with cerebral palsy patients and has a truly excellent safety record.  Dysport has been used for several years in Europe and Canada and at this point has shown no safety issues.

5.)  After a thorough review of the current literature we have determined that Dysport is a safe and effect alternative for Botox.  The cost of Dysport to is about 5-10% less than Botox and we will pass that savings on to our patients.  Dysport will run between $4 and $5 per unit.  Give us a call at 303.952.5787 to find out more or schedule an appointment to decide which product is right for you.

As always competition is a good thing.  The emergence of an alternative drug to Botox should spur on pricing competition that will benefit both patients and physicians alike.  Also new research and development is already under way to provide the next big product such a as Purtox.  Time and good clinical based studies will determine which products are truly clinically effective and which are more marketing hype.

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Collagen, Juverderm, Restylane, Radiesse and Sculptra Cost and Comparison

With all the lip and wrinkle fillers out there it is hard to know which on will be best for you. Is it collagen or Juvederm, maybe Restylane or Radiesse and what’s that Sculptra stuff all about?  I have created this short list to help you compare the cost, effectiveness and side effects of these products and determine which one is best for you.

Collagen:
This is the original filler.  It spreads beautifully and is one of the few products that can fill very fine lines.  Unlike like the original Zyderm and Zyplast which required skin testing, newer collages such as Cosmoderm and Cosmoplast do not.  The major drawback to collagen is although it is about the same price per unit as all of the other options listed hear it only last about 3 months. Each syringe contains about 1cc of product. Price is about $500-$600 per syringe.

Restylane:
Restylane was one of the first of a new type of fillers call Hyaluronic Acids or HAs for short.  The clear gel is made of crosslinked HA which can hold up to 1000 times its own weight in water.  HAs are naturally found in the skin and would normally breakdown quite quickly but due to its crosslinking, Restylane normally last about 6 months.  It can be used just about anywhere including the lips.  Another nice thing about all HAs, the product can be removed in a matter of hours if necessary with an enzyme call hyaluronidase which digests the HAs.  Each syringe contains 0.8cc of product. Cost is about $500-$600 per syringe.

Juvederm:
Juvederm is a second generation HA.  It has higher crosslinking so it last a bit longer than Restylane, normally about 9 months.  Juvederm is also a smooth gel which makes it less likely to look lumpy under the skin.  Both Juvederm and Restylane are about the same cost.  Each syringe contains 0.8cc of product. Price is about $500-$600 per syringe.

Radiesse:
Radiesse is made of Calcium Hydroxylapatite which is a natural mineral in your own body.  This is what we call a collagen stimulating product.  That means that not only does the product increase volume but it also stimulates your own tissue to produce more collagen.  Radiesse is good for deeper lines and for those that want a longer lasting treatment.  This product is NOT appropriate for the lips or fine lines.  Radiesse normally last about one year and may require a small touch up around 3-6 months.  Rarely patients have had mild allergic reaction to Radiesse which show up a prolonged redness over the injection site.  Per unit Radiesse is about the same price a Juvederm and Restylane for a 0.8cc syringe but it also comes in larger volumes of 1.5cc (almost 90% more product for only about 40% cost). Cost is about $500-$800 per syringe.

Sculptra:
Sculptra is solely a stimulatory filler.  In other words, one does not notice a change from the product itself but rather from the increased tissue collagen that is produced gradually over time after the produce has been placed.   Sculptra just received its cosmetic FDA approval in July 2009 but has been used for cosmetic purposed for over 5 years.  This product is made of Poly-L-Lactic Acid or PLLA for short.  This is same stuff we make absorbable stiches out of so we know it is very safe.  Sculptra takes about 3-6 months to do its job but it lasts over three years in many cases.  This product normally takes 3 injection sessions spaced about 6-8 weeks apart.  It is best for those that need deep volume throughout the face.  Side effects can include small papules under the skin if the product is not placed, spread or massaged properly.  Cost is about $1200 per treatment.

All of these products are broken down fully by the body unlike Silicone, Artecol and Artefill which should be avoided in most cases.

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Treatment for Bruising and Swelling

We often get questions about what patients can do to decrease the amount of bruising or swelling after a procedure.  Patients want to know what are the most effective ways to make bruising and swelling go away.  The good news is that there are effective steps that can both decrease the likelihood of bruising or swelling and decrease healing time.

Avoid:

Before any invasive procedure or other treatments that may alter the integrity of the skin such as Botox or Fillers make sure you should avoid certain vitamins and supplements.  Stop taking all of the following for at least one week:

NSAIDS (Advil, Motrin, Aleve)
Omega 3 fatty acids (Fish Oil)
Flax Seed Oil
Vitamin E
St. John’s Wart
Garlic
Ginko
Ginseng

A special note about aspirin:  It would need to be stopped for 10-14 days before a procedure but check with you prescribing physician first to see if it is ok to stop this medication.

Most minor bruising lasts a couple days to a couple weeks so be patients.  Keep firm pressure on any area that is obviously swelling for at least 5 minutes.  Place cool packs over the area immediately after treatment and for the first 24 hours (no hot packs).  Keep the area elevated for the first few days, especially at night.

Supplements:

There are two main supplements that have been proven to reduce the healing time of bruising and swelling.  In some studies healing times have been decreased by as much as 40%.

  • Arnica Montana can be very effective, the oral forms like SinEcch are much more effective that topical gels. It is even more effective when both forms are used together. Take the tablets as directed and apply gel 4-6 times a day.
  • Bromelain (an enzyme found in pineapple) also helps to minimize the bruising by helping to digest the proteins that trigger bruising and swelling. Take 250-500mg four times a day until the bruise heals.

 

Make-up Tips

Remember that green tinted make-ups will help decrease redness and yellow make-up will help absorb bluish discoloration.

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