Archive for March, 2010

Facial Rejuvenation For the Thin Patient

Wednesday, March 31st, 2010

Pan-facial atrophy. The 21st century word for the aging face. As fat and bone, muscle, and skin whither, the face shrinks and wrinkles. Most important, the face looks older. To my regret Google Tyra Banks and Sandra Bullock. What a shame these 2 lovely ladies don’t understand the gestalt they communicate with their newly minted gaunt appearance. It seems strange that in a country where our primary health problem is obesity, a new generation of women and some men seek to enhance their appearance with an asthenic appearance.
Pan-facial atrophy, the whithered aging face, is a natural product of aging and is enhanced when adults do not maintain adequate body weight to support their skin envelope. For people with normal body weight the best solution is fat transfer from a more robust area of the body such as abdomen or hips to the depleted cosmetic units of the face: the temples, the cheeks, the mouth, and in front of the ears. However, it is not uncommon to see patients who have normal to low body fat and aging withered faces, for whom gaining weight is not a psychological option.
The answer for them is Sculptra, poly-L-lactic acid. Poly-L-lactic acid is a synthetic particulate which can be produced as minute fibers that can be suspended in salt water and then injected under the skin. Once injected, this alpha-hydroxy acid acts as a biostimulant to induce collagen production in both fat and skin. There is some consideration in Europe that when layered over bone the collagen may cover the bone and in some way add to its bulk. Regardless, the new collagen restores depth to the subcutaneous layers and, when properly distributed, restores normal contours to the aging face.
Like previous fillers, hyaluronic acid (Restylane, Juvaderm) and collagen, poly-L lactic acid is naturally metabolized in tissue and presents no harmful foreign tissue. Unlike these other fillers the Sculptra fiber does not provide the bulk needed to restore normal contour but rather induces our own body to generate tissue needed to restore shape.
Sculptra is not a new product and was successfully used 10 years ago to treat the facial ravages of HIV patients who had been treated with antiviral agents. It was quickly recognized that it had great potential for treating cosmetic patients. Unfortunately, the dilutions that were recommended and used were too concentrated and they induced unsightly nodules in some patient’s skin. There are numerous, probably exaggerated, horror stories on the web of patients treated with Sculptra. Now however, following reports by Dr. Rebecca Fitzgerald of some 2000 patient interventions treated at UCLA and by Dr Neil Sadick of some 1000 patient interventions in New York City, it is recognized that this is a very safe product when diluted and injected correctly. To protect the public the company, Dermik Sanofi-Aventis, has stipulated that it will not sell its products to medispas or non-board certified cosmetic and plastic surgeons.
This is the first practical use of a group of compounds which will be developed over the next decade that will reverse the stigma of an aging face by inducing the human body to regenerate tissue that was lost through aging and/or a low caloric lifestyle. We have implemented the Sculptra program at MetropolitanMD and Drs Rachel, Franco and I anticipate it quickly becoming the gold standard in facial rejuvenation. For patients who do not want to undergo a fat transfer procedure or who do not wish to gain weight, this is a most significant break-though in preventing and reversing facial aging.

The Mechanics and Treatment of the Aging Face

Wednesday, March 24th, 2010

The poor prune. Delicious and rich looking as it may be it is saddled with epithets like “prune-face”, a “wrinkled grape”, and a prune every morning keeps you “regular”. For a fruit whose taste is enjoyed by so many the euphemisms seem dishearteningly displaced and not the least metaphoric. I mean, isn’t the image of the aging face wrinkled and collapsed? Don’t we think of the elderly as sweet and interesting but not to be overindulged? Of course neither you (the reader) nor I know what it is like to be “old” but like a red face in an embarrassing moment we know it when we see it. And none of us want to be there.
That said, what is going on here? How is it that the firm and beautiful grape that makes such lovely wine becomes the wrinkled prune with time? How do our faces age and can we arrest time? Yes we pretty much know and yes we can arrest some of the aging process of the face. The obvious attempts by some actors and actresses with fat lips, pulled faces, and altered mouths hardly qualify as arrested aging. More like promoted grotesque. The reality is the subtle modifications best exemplified by Meryl Streep and Kate Winslet are difficult to discern and so pleasing to the eye.
Cosmetic surgeons agree that the aging process is one of deflation. The most noticeable changes are the loss of facial fat and with its disappearance the face collapses. More subtle changes include loss of muscle and bones. Bones atrophy and whither and this is especially noticeable in the orbital bones around the eyes and in the maxilla and mandible which frame the mouth. Eyes sink in, bags appear beneath the eyes (often accompanied by dark circles) and the mouth recedes into oblivion as lips vanish and withdraw into the recesses of the mouth. (The visuals are almost too much to bear). To this the skin envelope, hanging from attachments to formerly firm muscles and subcutaneous tissue, degenerates with elastotic changes due to damage from the sun and wrinkles in a prune-like fashion into an amorphous cover.
Yet there is some good news. Joel Pessa, MD. a surgeon in the Department of Plastic Surgery at University of Texas Southwestern Medical Center, has done extensive work on the fat compartments of the face. Because of his work we now know that fat is distributed into fat compartments and is not a confluent layer under the skin. This adds mightily to the work done by Roger Amar, MD, of French fame who observed that the form of the face follows the tension and thickness of the muscles of facial expression. Now, knowing where the muscles of facial expression exist and knowing where the compartments of fat exist, we can erase many of the signs of facial aging by enhancing these two structures.
In my opinion fat grafting is the best material with which to reconstruct these tissues. The reality is many of our patients, in fact those most in need, may not have enough fat to harvest and others do not want to share their fat with their face. (Shame, shame! Why look older and more gaunt by not keeping up your weight.) Facial fillers have created remarkable results in the past 10 years toward improving facial outcomes. What is important here is that injecting fillers into facial lines is not only passé, it looks unnatural. The medi-spas and the untrained practitioners of cosmetic enhancement and surgery who not recognize that a youthful face is properly structured are out of touch. They are penny wise and pound foolish. Restructuring the face requires not only proper placement of augmentation, but the time to do it correctly (Picasso did not sculpt in one day, why should facial rejuvenation be done with a single filler intervention?). Aging is a process and so is its remedy.
Next week, popularization of a collagen promoter to naturally recreate lost tissue in the aging face.

Oscar Nite II: Why Can’t A Woman Be More Like A Man

Wednesday, March 17th, 2010

Professor Higgins: “Why can’t a woman … be more like a man? Men are so faithful, gracious and nice. Men are so caring, sagacious and polite. So why can’t a woman … be more like a man?”
This is another version of “Men are from Mars, Women are from Venus”. Perhaps more chauvinistic and without acknowledging biases, yet trying to understand the differences between the sexes. And yes, there are differences. Perhaps they are due to hormonal influences, perhaps to genetics. Hell, 2 X’s are not equal to an x and a y whether we are talking about algebra or genomic determinants.
My computer guru calls his computers “He”. He says computers are male because they always do what he tells them. And yet might it be that males and females don’t ask the same questions or even see the same question in the same way? Might it be that the color green to a female is not the same color green to a male, or that 3 objects laid side by side representing a gun, a doll, and a baseball evoke different emotional responses in males and females.
Without question this is true of appearance. When a man looks in a mirror he sees a preconceived notion of how he appears, mythical as it might be. When my son was 5 years old he had a plastic vest that transformed him into The Incredible Hulk. One day I watched him don his muscles outfit, then walk in front of a mirror, flex his barely visible biceps and pecs, and roar as only The Hulk could do. Clearly, in his mirror, he was The Hulk. Not uncommonly that is how men see themselves as they prepare to go out for an evening.
By contrast, women prepare for a party by prepping their hair, putting on their fine clothes, maybe some jewelry and finally add a dash of provocative perfume. They go to the event feeling very beautiful and then a photographer asks if he may take a picture. After seeing the picture the party is over. Why is my nose so big or I can’t believe the pimple on my nose. My hair just isn’t right and I look older. Or worst, I look like I am bulging out of my clothes. The beautiful lady of a few hours ago has become Cinderella.
Women are simply more critical of themselves than are men. Both visualize themselves in the mirror or the photograph as they wish to be seen. But men have other attributes that they use to bolster their ego: wealth, muscles, strength, wit. Women still find themselves in the unenviable position of judging themselves by their sexuality. And this leads me back to Oscar night where the female actresses not only stole the show with panache. They did it with self-confidence. They had full figures, strong bodies, healthy demeanors, and intelligence. In my judgment they did not present themselves as sexual aperitifs but rather as healthy examples of beauty and self-worth in their gender. They can avail themselves of breakthroughs in cosmetic wellness without looking grotesque and emaciated. They can go to a cosmetic surgeon for non-invasive or invasive procedures to enhance their appearance without confusing their wish to be attractive (vanity), with narcissism.
In this regard men have a way to go. We still pretend to hunt the saber-toothed tiger and derive our self worth from our manliness. We are still afraid of our emotions and fear our own sense of narcissism when we want to look attractive and be accepted. And yet even here, the world is changing. 20% of men make up the population of people who have major or minor cosmetic improvements. Magazines that promote sensible dress are popular. For this we can take a page from women: healthy appearance begets a healthy response from others. Enhancing what we are given at birth: a musculoskeletal form; a soft round subcutaneous shell; and flexible, elastic, smooth skin is the opposite of narcissism. It is vanity in its finest sense of self-appreciation. We can do this with our knowledge of skin care, our fillers and Botox, our lasers and sometimes our knife. But always with perspective of what is healthy, natural, and long-lived, of what is a healthy life-style.
Next week: Looking at aging mechanistically and how we can modify its effects.

As Oscar Winning Actresses Excel A Few Faux Pas Stand Out

Wednesday, March 10th, 2010

The Oscar show is always a fun-filled affair, although mostly boring to the television viewer. For me it is an insight into popular social trends in the US especially as regards appearance. Last year I noted that the producers kept the anorexic youth characterized with their not so young leader Angelina Jolie in the audience and instead featured mature women on stage sporting full faces and bodies and appearing most beautiful. I need only refer to Kate Winslet and Meryl Streep.
This year the trend continued with two obvious additions. There were teen-aged actress presenters who looked healthy with few exceptions, although their dresses were less than flattering. And more importantly on stage were mature women with full bodies who now showed off muscular arms, shoulders, and necks - a result no doubt of some serious weight lifting. The emaciated look of half-starved and emotionally unhappy youth has been abandoned in favor of health and vigor and with it a much more mature and gracious appearance (delete that for a rather immature acceptance speech for Monique, an otherwise talented actress).
So with all due praise now rendered, it is time for me to give out awards for the worst appearing actress and her runner-up. In both cases the award is given for poor choices and in spite of the fact that I have very high regard for the social sophistication of both actresses.
The worst-face runner up clearly goes to Sarah Jessica Parker who mangled her skin and had the most peculiar hues I have seen on such a show. I don’t know if she sprayed herself with self-tanning solution or pickled her face in the sun but either way the color, texture, and hue of her face was not complementary. Also, her smile seemed constrained, though her personality was not, and could that have been the result of minor surgery or botox? I simply do not know. I continue to admire her work both in front of and behind the camera, yet she will grow drearily old before her time if she continues to hide behind poorly conceived cosmetic masks.
The winner of the worst face on Oscar night goes to Sandra Bullock who not only lost weight and aged her face but compounded it by framing her face with long hair making her face look even less attractive. She alluded to this in the red-carpet interview in which she said she will hurry to devour a hamburger and fries as soon as the event was over.
For me, this was the healthiest Oscar ever and the maturity, beauty, and grace of the female participants has not been equaled. The lessons for all of us are: a healthy and youthful face cannot be long and narrow; skinny adults look old; and long hair framing the face of an adult adds 10 years to appearance. There are now a panoply of treatments to produce a healthy and youthful face and I will address them next week. However, they all start with a healthy diet and a healthy attitude toward body shape.

If you are or will be a skin cancer patient: read this

Tuesday, March 2nd, 2010

Neoadjuvant Therapy. Adjuvant Therapy. Learn these words. One or the other may save your life if you get cancer. I am largely alive today because I was one of the first participants in a clinical trial using neoadjuvant therapy to treat my pancreatic cancer in 2002. I will write more about that later.
Neoadjuvant therapy can refer to treatments given to reduce tumor size or improve survival before definitive therapy such as surgery is performed. Adjuvant therapy is the use of drugs or other modalities after surgery to reduce the chance of surviving cancer cells from growing.
Skin cancer is the most prevalent cancer in the world. More than 1 million cases occur every year in the United States. It is the 7th leading cause of cancer death in the United States. It is the biggest single drain on the health care system of all cancers. It is promoted by sunlight and directly caused by suntan parlors. The odds of a patient who has had skin cancer developing another skin cancer is 30% over the next 3 years and 100% over a lifetime.
A patient came to see me today who told me about her husband who had skin cancer and a lot of sun exposure in his earlier life. He sees a dermatologist many times a year and at each visit the dermatologist “zaps” off lesions from his face. Yet no matter how many lesions are removed, at the next visit new ones have arisen. I think even a mule understands that when he is overheating in the sun and does not feel well, moving into shade gives relief. Yet here are millions of patients who go month after month, year after year, to get spots “zapped” with the “understanding” that this might prevent skin cancer. At best this is specious reasoning and between the doctor and the patient I am not sure who benefits most.
It was refreshing at the Orlando Dermatology Meeting last December to hear lectures on neoadjuvant and adjuvant therapy to prevent the onset of new lesions and ultimately to prevent new cancers. Remember these names- adjuvant and neoadjuvant. They are available for you now and will be the primary therapy for your children. The fact is patients have options on how to prevent cancer and what follows is a short list to consider:
• Topical vitamin A or tretinoin. Available as a gel or cream a little dab each night may prevent up to 90% of new cancers from arising. This has been known since 1980, yet few physicians recommend it to patients. Coincidentally it is used to treat wrinkles.
• 5-FU (5-fluorouracil): a known anticancer drug for breast and colon, it has been used for years as a cream to treat precancerous lesions. New evidence suggests using it for one week out of the year may prevent even these precancerous lesions from forming.
• PDT (photodynamic therapy): consists of applying a chemical, aminolevulinic acid, to the skin followed by intense light or laser therapy. With more than 20 years experience in Europe it is very successful in treating precancerous lesions and small cancers and is a very popular skin rejuvenation treatment. Like vitamin A you get two for the price of one: better health and better looks.
• Fractional Laser Resurfacing: While not yet successful as a preventive, this is another 1-2 punch making you look better and removing precancerous lesions.
In the 21st century it is archaic to get lesions “zapped” and do nothing to prevent skin cancer and its precancerous growths. In an age where we look to legislation to reduce health care expenditures it is incumbent upon each of us to utilize preventive measures to treat and prevent skin cancer. Well, the time is here and the methods are available. Are you?