TCA Peels

TCA or Trichloroacetic acid, a derivative of the acid used to make vinegar, next to glycolic acid, is the most common peeling agent used today. It has been used safely since the early part of the 20^th century as peeling agent for superficial and medium depth peels.

It is used in concentrations from 10 to 50% both singly and in combination with other agents such as glycolic acid, salicylic acid, lactic acid, resorcinol, and retinoic acid. It is the basis for the “Obagi Blue Peel™”. It works well on the face, extremities and back. It can be used as frequently as bi-weekly

Predictable with little down time, it is safe with no toxicity when used in concentrations of 20-35%. It is one of the best cosmetic procedures available today and its results are on par with the more expensive laser and photo-light procedures.

It is undergoing resurgence in popularity as the limitations, expense and complications of lasers are becoming more apparent.  

Alpha Hydroxy Acids (AHAs)

Alpha Hydroxy Acids or AHA’s are acids that naturally occur in nature and are derived from fruit, milk, and sugar cane. Their re-appearred on cosmoceutical stage about 15 years ago with  explosive growth and popularity. They have totally re-made the cosmoceutical industry and created a plethora of new products and new companies which in turn spurred on by the impetus provided by the AHA revolution developed even more new products.

The AHA family:

• Citric (citrus fruit)
• Glycolic (sugar cane)
• Lactic (milk)
• Malic (apples)
• Tartaric (grapes)

The Glycolic acid is by a far the most used of these acids, both as peeling agent and in various home treatment creams. Used correctly is a very safe effective treatment for a wide variety of skin disorders. It aids in the treatment of acne, solar damage, pre cancers( though not as well as TCA), skin rejuvenation, and pigmentation disorders. Derivatives of glycolic acid, mandelic acid and gluconic acid, are also used in cosmoceutical products.

As peeling agents, Glycolic is the most frequently used of this family. Concentrations of 30- 70% with 50% being the most common are used in physicians’ offices. This acid as opposed to TCA, although considered “weaker”, requires monitoring and neutralization. (TCA is neutralized by cellular fluids). After preparation of the skin and application of the acid, it is normally left on the skin for 2-4 minutes, then neutralized with sodium bicarbonate (baking soda) solution. The skin is monitored during application time for any evidence  fo “flashing’” that might indicate a quicker response by the  skin especially more sensitive or prior use of tretinoin (Retin A). Concentrations of 70% concentration not properly monitored and neutralized have caused scarring. Personally I feel 70% should be applied only by a physician or the extremely well trained professional (nurse or esthetician).

The majority of glycolic peels performed by estheticians in salons or spas use prepackaged solutions of 20-30% from reputable companies following the companies’ instructions. They can be done weekly or bi-weekly with good results.

At home use of 5- 20% glycolic creams are a mainstay in exfoliation therapy which plays a key part in a skin rejuvenation regimen. The exfoliation not only  stimuates new collagen growth but it also aids treatment with of other products such as Niacin (Nia24), Vitamin C (SkinCeuticals), Retinols (Dr. Grandel) and Growth hormone(TNS- Skinmedica) by enhancing absorption. Glycolic acid has also been formulated using lactic acid, its derivatives, retinols, Vitamin C, and Vitamin E in a myriad of combinations creating very effective home skin rejuvenation products.

Micro-Dermabrasion, a  painless, non-invasive effective  skincare treatment that arrived on the Cosmetic Dermtatology scene has  become one of  the  most popular  therapies being offered in salons and physicians offices.

It is a simple process  of lightly abrading away the superficial dry dead cells of the outer skin layer, that block pores, by propelling white micro crystals( carbide, sand, salt or other small hard particles) across the skin with a suction activated instrument.

When combined with modern cleansers, glycolic exfoliants and powerful anti-oxidant moisturizers, skin circulation, stimulation and rejuvenation are immediate and impressive.

Affordable, suitable and adaptable to all skin types and conditions, from juvenile acne to age spots, no one need feel left out of the skin rejuvenation revolution.

No skin treatment in history has been so immediately and favorably embraced by those who are concerned about skin health and beauty.  The immediate improvement in skin translucency, luster, texture and vibrancy leaves no doubt that Science for Skin has delivered the long awaited “fountain of youth” treatment

Safe, painless, less invasive and less expensive than chemical peels and laser resurfacing, the recovery time from even the most aggressive treatment in severe conditions is but a few days as compared to weeks or months following those alternative procedures.

Makeup can be reapplied immediately following a routine treatment

There are no messy, painful dressing changes, and no persistent redness that may last for several months, as with some laser and heavy duty chemical peels.

With micro-dermabrasion you can be treated this week and look great for that big social event next week without any downtime

Dermabrasion

The removal of the top layer(s) of skin most commonly using motor driven wire brush or diamond encrusted wheel (fraize) at high speed. Manual dermabrasion using salt, sandpaper and dry wall sanders has had limited use but are not as effective as the motor driven method.

There are many conditions that can be treated using this procedure however the condition most frequently treated with this is acne scarring. Dermabrasion is considered the “gold standard” in acne scar treatment by which all other methods of treatment are measured (lasers, chemical peels).

The procedure was popular in the 60s, 70’s and early 80’s but has been largely supplanted by lasers. This procedure is extremely technique driven (must have a skilled operator for a good results and to avoid complications) with a high learning curve. Because of this with the advent of lasers, it is less frequently used and there is less number of physicians trained in its technique. It is much easier to teach someone the correct way to use laser versus using a wire brush at rotating at 30000 rpm or a diamond wheel at 50-80000 rpm which as it requires a firm deft touch. Also to get best result it is desirable for the skin needs to be immobilized either with freezing or recently tumescent anesthesia popularized by liposuction has migrated over and has been used with good results.

Complications are scarring (too deep), injury to vital structures (lips, eyes, nose), and hypertrophic scarring at the jawline or cheekbones (can happen in best of hands).

Botox

Botox, the magic elixir. The most commonly preformed cosmetic procedure in the US is Botox injections

Botox is botulinum toxin type A produced by the bacterium Clostridia botulinum. In the old days it ruined a few church picnics due to Aunt Millie’s improper canning of the green beans. Now for the last 20 years, in very small dilute doses, is used as the foundation of beauty. Initially used in treatment of muscle spasm disorders around the eye its ability to lessen the appearance of wrinkles was recognized by the Drs. Carruthers in Vancouver Canada. First used for the area the between the eyes the use quickly spread to other areas.

Currently it continues to be used primarily for the area between the eyebrows and the crow’s feet. However the envelope keeping being pushed and now Botox is used in the forehead, around the lips, the chin, the neck bands, and even one MD from Mexico is using it for “breast lifts” by injecting the muscles below the breast. Botox has been used to control excessive sweating of the palms and axillae, tension headaches, back spasms, whip lash and vocal cord spasm.

Botox is extremely safe. In the millions of doses given, there have been no reports of death or serious injury. Botox should not be used if someone has a neuromuscular disease such as myasthenia gravis, pregnant or breast feeding.

Botox comes in a powder form in a vial of a 100 units. It is diluted with saline and injected. The amount used varies with the areas to be treated and judgment of the injector. Everyone is unique and each will have different effect and duration of the Botox. I have found that certain people need retreating in 2-3 months and others can go a year between sessions. I notice that type a people (fast movers) such as women realtors, young, work out frequently tend to need more sooner, versus the laid back types who go much longer. Gender also plays a role as men require about twice the amount in an area especially the forehead to get the same result a small women would get.

Results: the look I want to achieve is improvement in the overall facial unit with a rested appearance. I do not want a “frozen” face where there is no natural movement when gesticulating or speaking. Some patients, usually first timers, feel they didn’t get their money’s worth if the can produce even the slightest wrinkle or wiggle of the forehead. The ‘knife” cut wrinkle between the eyes that seems prominent in businesswomen and teachers  will be lessened with the first few sessions but normally takes several treatments to relax the muscle enough to eradicate it.

Price. Botox is produced by one company, Allergan. The price seems to increase every six months. Some injectors charge by the area, others by the volume, and others by the number of units. By and large the average cost is about $350-$575 for treating between the eyes, forehead and crow’s feet. I charge more for treating the lips even though the Botox is diluted( done to avoid a non functioning mouth or drooling) as I usually perform a short acting nerve block as even with topical anesthesia the lips are extremely sensitive.

TUMESCENT LIPOSUCTION

Liposuction surgery has become the most popular cosmetic procedure performed in this country. Although generally a safe procedure, it has been made even safer by the elimination of general anesthesia through the use of the Tumescent Liposuction Technique. There is minimal blood loss; therefore no transfuswns are necessary. In addition, thinner cannulas (the small hollow tubes through which the fat is suctioned) allow the surgeon to make smaller incisions and to achieve a smoother result. This refined technique is termed “Liposculpture” “.

 Frequently asked questions:

1: What is Liposuction Surgery?

 Liposuction Surgery is the removal of unwanted bulges created by excess localized fat deposiis. These form due to hereditary factors (familial traits) and gender (male versus female). A cannula is inserted through tiny skin incisions placed in inconspicuous locations and attached to a vacuum pump.

2: What is the Tumescent Technique?

 The Tumescent Technique uses a  large volume of a dilute solution of  lidocaine( a local anesthetic and normal saline), with  epinephrine,( to  temporarily shrink the capillaries). This technique minimizes the need for  intravenous sedatives, narcotic analgesics, or general anesthesia. Also postoperative discomfort is reduced by the local anesthesia which  remains in the treated areas for approximately 18-24 hours following surgery; Tylenol is normally all that is required byy patients  post-op discomfort. The effect of the epinephrine and large volumes of saline reduces bleeding during surgery,  and with that  post­operative bruising and swelling  as opposed to  compared to liposuction under general anesthesia.  Minimal brusing means less pain, quicker healig and decreased recovery time. Manyt patients return to work and resume exercising within a day or two after surgery. Continous uUse of  elastic support garments  is recommended  for the first week, then daily or nightly for 3 weeks.

3: Which areas can be  treated?

 Almost any area of the body can be treated. The most common area treated is the outer thigh area in women, commonly referred to as “saddle bags” or “riding breeches” followed by the abdomen. In men it is the  flanks (Love handles). Facial areas such chins and jowls, the hips, buttocks, thighs, knees, and ankles. Breast reduction in both  men and women is also popular.

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4: Who is a good candidate for Liposuction surgery?

Ideally healthy athletic individuals on an exercise program and of normal body weight who have done  everything possible to lose the unwanted localized fat accumulation  are the best for this treatment.

Moderately over­weigh patients  are  still e candidates for this surgery. All patients must  have realistic expectations of what can be achieved. Age by itself is not a signifiicant factor as long as  patient should be in good general health. Caution: This technique is not to be used as a substitute for weight loss.  There is a limit as to how much fat can be removed safely at one time.  However   many overweight patients can be happy with an improvement in contour.

5: Is it is a dangerous procedure?

Liposuction is amazingly safe. Serious complications such as blood clots, infection and allergic reactions are extremely rare.  Most of the dangers associated with any  surgery is  related to the type of anesthesia that is used. Surgery of the skin and subcutaneous fat is safest using local anesthesia with the patient awake .  Any surgical procedure carries the risk of  side-effects such as bruising, swelling, and temporary numbness. In liposuction a common side-effect is irregularities of the skin however theTumescent technique  minimizes this compared to the "dry technique".

6: Where is Tumescent liposuction surgery performed?

- This is usually an in-office procedure. Oral medications can  be used to allay anxiety before the procedure for patients.  A surgicenter is an option for those who may require  heavier medications or IV sedation with an anesthesiologist.

7: What is the recovery period?

The recovery time varies with how many areas are treated and the type of activity the patient intends to resume. Most patients are performing routine duties after two days, but in some cases five of six days of “recovery time” may be necessary. Soreness is minimal for the first 24 hours and peaks between 3 and 5 days after surgery. Extra-strength Tylenol is usually sufficient to control the discomfort.  Rarely  stronger pain medications may be required.

8: Will there be bandages?

Special compression garments are worn under clothing usually 24 hours daily for one week then 12 hours daily for an additional 2 weeks. Gauze or sanitary napkins are used for the first several days to absorb the drainage of anesthetic fluid In some areas, a special tape may be applied to the skin. Patients who have had the neck done will wear a chin strap for one to several days.

9: Will the fat re-grow?

Once  puberty is reached no new fat cells develop. The fat cells either swell or shrink in size depending on weight gain or loss. When fat cells are removed from a treated area they do not return. Liposuction is indeed the only true spot reducer. The patient’s new more pleasing silhouette is permanent. If weight is later gained or lost, the change tends to be distr buted proportionately over the entire body.

10: What will happen to the excess skin?

 Skin is a dynamic organ which has elasticity and in most cases is able to shrink and re­accommodate to the new body contour. Those who are poor candidates for Liposuction surgery because of decreased skin elasticity can have the excess skin removed ~f they so desire at a later date. In our experience this is almost never necessary.

11: Can the procedure be repeated?

Yes.  Many patients have had areas touched up or new areas treated. There is a maximume amount  fat that can be extracted during any one operation so a repeat procedure may be necessary to achieve the result desired.

12: When are results visible?

Usually within one day about 90% of patients will see improvement in their silhouette.  The finial results following liposuction will be 3 to 6 months.

13: Will I lose weight?

As fat weighs very little, weight loss is minimal.  The purpose of the procedure is to sculpt the body and change the shihouette. You will probably lose inches and look slimmer. The appearance of cellu?ite is occasionally improved. This is not a weight control treatment.

14: What are the alternatives?

Although diet and exercise help with weight reduction, the body’s shape may stay relatively the same without liposuction. Direct surgical removal such as a tummy tuck is possible, but may result in large scars. The last alternative is to elect no treatment - - leave “well enough” alone.

15: What are the limitations of liposuction?

This is not a good treatment of cellulite as it is usually unchanged or  improved. There will always be a difference in body symmetry. Patients who expect prefection will be disappointed. You have to be realistic and be happy with 60-80% improvemen which is what most achieve but ,you  should be willing to accept 50 per cent improvement in order to be considered a candidate for liposuction.