SKIN CARE

One of the most rapidly-expanding areas of cosmetic surgery is skin care and the treatment of the wrinkles and lines that inevitably appear with time. A wide spectrum of treatments is available. The simplest version is the daily application of a series of preparations that exfoliate the skin and produce, in effect, a very light peel. This results in skin that is softer and smoother. The treatments can also be used to improve a number of different skin conditions, including fine wrinkling, sun damage, blotchy pigmentation and dark patches, superficial acne scarring and age spots.

The bases for these treatments are any of a number of light acids such as Retin-A or alpha-hydroxy acids (e.g., glycolic acid and lactic acid). The preparations are applied to the face every night for several weeks, until improvement is achieved, and about twice a week thereafter. Other areas of the body, such as the hands, arms and shoulders, can also be treated. Dry, flaky skin can be expected during the first phase of treatment; this is, in fact, the "light peel". A moisturizer should be used and, as with other forms of exfoliations and peels, a sunblock. We use the MD Forte system, which contains glycolic acid as the active ingredient. Among the products available are a facial cleanser (15% glycolic acid), two facial creams (15% and 20%), a hydrating complex, a hand and body cream (20%), a sun screen, a skin rejuvenation lotion, and a rejuvenation eye cream.

Conditions involving deeper layers of the skin, such as wrinkling (particularly around the upper lip, mouth and eyes), and acne scarring, often are treated most effectively with resurfacing procedures, such as laser, chemical peels or dermabrasion, since the exfoliation described above is not adequate. All three modalities diminish wrinkling and produce a more youthful appearance by removing superficial layers of the skin.

Resurfacing, whether through laser, chemical peels or dermabrasion can be light, medium or deep. The use of different techniques and chemicals is responsible for this variation in depth. Deep resurfacing procedures produce more dramatic improvement than light ones, but also have a longer recovery time, and have increased risks. For this reason, a series of light to moderate procedures is often recommended in place of a single deep one. The skin is generally extra sensitive to sunlight after resurfacing, and a sunblock must be used daily. Not all skin types are equally good candidates for these procedures. In general, lighter-colored skin is considered better since darker skin may have an increased risk of pigmentary (color) changes and scarring with these procedures.

The latest technology in this field is the laser. The most popular lasers currently in use are the carbon dioxide laser and the erbium laser. Alternatively, a variety of chemicals can be used to produce a chemical peel. These are applied directly onto the areas of the skin that are to be improved, and through chemical action the affected layers of the skin are removed. Dermabrasion, now largely replaced by lasers and chemical peels though equally effective in experienced hands, is the controlled scraping and resurfacing of the upper skin layers.

Other methods of treatment include the injection of filler materials, which can generally be divided into "temporary' and "permanent". Although it would seem that permanent materials are the most desirable, there is an incidence of problems that can occur over time that limits some of the appeal. Fillers are used to diminish the appearance of folds and lines on the face, particularly the furrows that extend from the nose to the corners of the mouth (nasolabial lines) and from the mouth to the chin (marionnette lines). They work by "puffing up" the area in question to bring it more into line with the surrounding contours. They can also be used to create fuller lips, including the lower and/or the upper lip. Several sessions may be required for the best results. Makeup can be applied directly on the treated areas. These substances are packaged in pre-filled syringes with specific amounts of the material in each syringe. The cost of the treatment depends, among other factors, on the number (and size) of syringes used.

The most effective of the temporary fillers is Restylane a stabilized form of hyaluronic acid that is formed into a gel. Because it is non-animal derived (it is made in a laboratory) no testing is required and the risk of an allergic reaction is basically zero. Restylane has been used since 1996 in Europe and Canada, where over 500,000 people have been treated with remarkably few complications. It typically lasts from 6-12 months. The best known filler, however, is collagen, marketed as Zyderm/Zyplast, a purified protein which, after test doses are used to preclude an allergic response, can provide correction for 4-6 months. Mild overcorrection must be accomplished at the time of treatment, since water and lidocaine (an anesthetic) are contained within the collagen material and are rapidly absorbed. A newer form of collagen, derived from cultured human fibroblast cells, is called Cosmoderm/Cosmoplast. Restylane does not contain an anesthetic and, for that reason, it is often advisable to have the areas that will be treated numbed prior to the treatments themselves. Many other permanent and temporary substances are used in the rapidly growing field of injectable fillers.

Another approach is to weaken the muscles that, when contracted, produce the fine lines and wrinkles on the face. The injection of a purified botulin toxin (Botox®) produces a temporary (weeks to months) paralysis of specific muscle groups in the face. It is used most commonly for the forehead, eyebrows, and around the eyes. Although it diminishes facial expression in the regions being treated and is temporary, the overall effect, including the lessening of lines, is often beneficial.

Yet another approach is to insert a permanent filler material, such as an implant. For example, a polytetrafluoroethylene graft, similar to what is used for blood vessel surgery elsewhere in the body, is used for the deep nasolabial folds. Inserted through two small (~ 2 mm) incisions, this graft elevates the skin of the fold and diminishes the fold itself. As with all facial implants, there is a risk of infection, and the implants, if placed incorrectly or if shifting occurs with time, may be difficult to remove (if that becomes necessary,) and may leave some scar tissue or other irregularities in the regions that were treated.