Topical Skin Regimens and Vitamin C

Recently, seen several articles that suggest topical Vitamin C creams to keep skin from aging. Also have read that it helps minimize sun damage. I think Skinceuticals makes one and La Roche-Posay, for example.

Do you think there is any benefit from these? Also, does taking Vit. C orally help?


yes,
vit c is a good antioxidant - helps to treat sun damage and environmental oxidative stress.
there's c and e ferrulic by skin ceuticals - that's good.
also, prevage is a good antioxidant.
i carry both of those.
you need to use them regularly for a while to see results, but its certainly good for you. oral vit c has not been shown to be of any benefit - you get enough of that in your diet.
retin a (tazorac, retin a micro, etc), moisturizer, sun screen and a gentle cleanser are also good to use. that's my basic topical recommendations.
cheers

Botox and Brow Droop

2 weeks ago, I had what I believe was .2units of botox to the forehead. I am suffering with heavily hooded eyes as a result although all wrinkes on the forehead are gone. Plastic surgeon since added botox between end of eyes and end of brow but no improvement and I look exhausted.
Can hyalurondase reverse these effects and if so, how long will it take?


hi suzy,
i'm afraid not
hyaluronidase is for hyaluronic acid only - juvederm and restylane, not for botox.
.2 is not your units - its probably 16 to 20. you should find out because you definitely want less than that the next time.
there is an eye drop that you can try called iopidine. it may not help, but its worth a shot.
the reason why this happened is that the muscles of your forehead hold your brows up. if you weaken the muscles too much, your brow drops.
unfortunately, when this kind of thing happens, you usually have to wait it out until the botox effect weakens. it usually takes about 6 weeks or so. that's why i always undertreat the forehead - i can always put in more later and i hate to have this kind of thing happen.
sorry about that

http://www.westsidemedicalspa.com/botox.html

Laser Resurfacing

My dermatologist offers a laser treatment for skin "resurfacing" (ouch!) which is different from the laser at my favorite medispa. Are all lasers the same? How do I make sure they use the right one?



I think that the first thing you should figure out is what kind of results you are looking for. Each laser or device is a tool that has specific uses and limitations. The best way to make sure that you are using the appropriate technology is to first define what kinds of changes you want to see - what do you mean by "resurfacing?"

If you're in your 30s and you're just talking about brown spots from sun damage, then IPL may be your best bet. There is little to no downtime and it fades these spots well. I recommend IPL to patients who do not want to incur major downtime and who do not have issues with fine lines, large pores or acne scars. It is cheap and easy, although you do usually have to do multiple treatments. One piece of advice about IPL - don't think that packages of 5 treatments are absolutely necessary. I offer packages but usually tell people that less treatments may work well - nothing wrong with playing it by ear.

If by resurfacing you mean fine lines, enlarged pores as well as brown spots, then more invasive laser treament would be appropriate. The fractionated CO2 lasers are all the rage now and they really do represent an important advance in our ability to correct fine lines, pores and what i call the "topography" of the skin. I use the Active Fx / Deep Fx with good results - the laser has been around for a couple of years and is safe and effective. The downtime is significant - 4 days at home and then about a week where you look like you have a sunburn - but nothing like the pain, redness and swelling of operative CO2 laser resurfacing (which is falling out of favor as these fractionated devices become more popular). I notice that the fractionated CO2 is especially good for lines around the eyes and lips - areas where no other laser seems to make much of a difference. The other advantage of the CO2 devices is that less treatments are needed. Generally one to two sessions are sufficient, as opposed to the 5 or more sessions with the traditional Erbium Fraxel laser.

Acne scars are tough to get rid of. I use the Deep Fx and the results are quite good, but 2 sessions are almost always necessary and there is a bit more downtime. The laser companies say that there is collagen stimulation benefit from the CO2 laser which will improve results over the 6 months after treatment. I'm not sure if that's true or not, but we'll see.

Differences between the CO2 devices are minor, but not insignificant. The Mixto is an Italian device - it is not as versatile or as well supported as the American Active Fx and Fraxel re:pair. It's alot cheaper (for the doctor), but I think that it is not as reliable and cannot treat the variety of skin types and conditions that the other two treat. The Fraxel and the Active Fx are equally good and get similar results.Both devices have more depth of penetration and density than any patient needs - I would never max out either device in the clinic - so this is really not a differentiating factor. I got the Active Fx because it has been out on the market for several years and its safety record is good. The Fraxel is a new device that has also been seen to be quite safe since its release over the last few months, but it is still new.

If you're going to go for one of the CO2 lasers, make sure that the doctor has had plenty of experience and that he or she is either closely involved with the treatment or actually performing the procedure.

Lumpy Lips

Hi can you advise me, I had my top lip filled with Restylane Lipp on Saturday...although the swelling has gone I have a few lumps in my lip. One in particular is bothering me as it's large and feels a bit numb. You can also see it as it is making that side look mishapen. Is this normal?


hi,
yes, this should be quite normal.
its very common to get some bumpiness right afterwards that resolves after a week or two.
i wouldn't worry about it. one thing you can do is massage the lip to try to smooth it out gently.
that should work well.
if it doesn't resolve soon, talk to your injector and see what he or she recommends.
hope that helps

Botox Issues

I HAD MY VERY FIRST BOTOX INJECTIONS AT AGE 45 LAST FRIDAY. I DO NOT KNOW HOW MANY UNITS WERE USED - I THINK ABOUT 3 INJECTIONS TO MY FOREHEAD ( I HAD VERY BAD HORIZONTAL LINES ALL THE WAY ACROSS - NO #11 SIGN AS YOU CALL IT) i ASKED FOR FILLER BUT THE PS SAID IT WOULD NOT WORK. AND SOLD ME ON BOTOX WHICH I NEVER THOUGHT I WOULD EVER USE. ALSO 2 INJECTIONS AROUND CROWS FEET AS I RECALL. HE TOLD ME HE THOUGHT HE WOULD USE STANDARD DOSE OF 2CCS?

WITHIN THE DAY- I AM VERY FAIR, MY FOREHEAD WAS COMPLETELY CHANGED - ALMOST ALL LINES GONE., ALTHOUGH IT FEELS STILL VERY TIGHT AND ALMOST IMPOSSIBLE TO MOVE - THOUGH THERE IS SOME EXPRESSION STILL.

HOWEVER ON DAY 3 I REALLY NOTICED MY EYES LOOKED NOT LIKE MY EYES. MY EYES WERE ALWAYS MY BEST FEATIURE AND I DONT EVEN RECOGNIZE MYSELF. THEY LOOK ELONGATED WITH THE LIDS SEEMING A LITTLE LOWER AS WELL AS THE BROWS, NOT SURE HOW TO DESCRIBE IT- NOT REALLY CAT EYE - BUT I LOOK MEAN ALL THE TIME UNLESS I SMILE - THEN MY EYE LOOKS ALMOST NORMAL.

I AM DUE TO GO BACK FOR MY FOLLOW UP NEXT WEEK. HELP?? I HAVE READ THIS COULD LAST 3 MONTHS OR MORE?? NO ONE EVER TOLD ME MY EYES WOULD LOOK DIFFERENT - ALL I WANTED WAS MY FOREHEAD LINES GONE. IF I COULD HAVE SEEN AN AFTER PICTURE I WOULD NEVER HAVE DONE THIS. I KNOW SOMETHING HAS HAPPEND TOO BECAUSE WHEN I DO MY BROW PENCIL IT SEEMS LIKE WHAT ARCH I HAD IS GONE. WILL MY BROWS LIFT BACK UP ANYTIME SOON> IT SEEMS BOTH FELL A BIT RIGHT OVER THE IRIS. ITS NOT DROOPY LIKE SOME DESCRIBE BUT IT IS NOT MY EYE!

I DID GET AND STILL HAVE SOME HEADACHES ALSO - AND MY FOREHEAD AREA FEELS VERY TIGHT AND HEAVY.

OH HELP!!!! Sad


hi,
it sounds like he put too much botox in your forehead.
the "standard" dose that the company recommends is usually too much for the forehead, but when its the first time and you have prominent lines its hard to tell before you inject.
if he injects more botox around the tail of you eyebrows (about 2 to 4 units per side), he can make the brows come up a bit and help lessen the heaviness.
the effect will last a few weeks at least, but probably not 3 months.
within 4 to 6 weeks you should be alot better.

Gram Negative Acne and Blue Light?

Dr. Rivkin,

Do you know if the Blue LED light treatment is effective if a person has gram negative acne?

Thanks


hi,
well, the acne bacterium is called Propionibacterium acnes. it is a gram positive anaerobic bacterium. i don't know of any gram negative acne, all though there is a condition called gram negative folliculitis that looks like acne. it is a rare condition caused by prolonged treatment of acne by certain antibiotics.
blue light only works on the gram postive p.acnes bacteria, not on the folliculitis. if you have that, antibiotics that cover gram negative bacteria should be used. if that doesn't work, you may have to go for accutane.
i would be very sure of the diagnosis first, however (i.e. get a second opinion if necessary).

Juvederm vs Restylane vs Aquamid for the Lips

I went in for a consult today and told them I wanted to try Juvederm primarily for my upper vermillion border but I also had a smile line I wanted to smooth out. I was very surprised by their recommendation and wanted to confirm this with you. I was told that Restylane is better for the vermillion border given that it is more firm and Juvederm is more liquid which makes it harder to accentuate this area properly. She said her clients who started with Resty and switched to Juvey were not as happy.

Then when I told her I wanted to fill my left smile line, she had me smile to look at it better and said that because it is an expression line and not in the NL fold, that it doesn't fill well. She said it often looks too puffed up and unnatural when filled. We also discussed 8 units of botox all the way around my mouth since all of my lip lines are from expressions and she plans to put another 2 units in my left cheek area to help with the smile line.

Needless to say I left there totally confused. I have heard people generally like Juvey more than Resty and also that it lasts longer and has helped them build collagen. I had hoped the Juvey would last long enough on me that by the time it wore off Aquamid would be available as I would really rather have something long-term. And I had never heard that smile lines aren't good to fill. Can you clarify on all of this? And if I could have any filler on the market right now, given that we know Aquamid is not that far away, what would you recommend for my lips?

Thank you!


hi,
well, first off, aquamid is still a year or more away, unfortunately.
i use juvederm in the vermillion border and have not had any problems - people like it just fine and i have not had complaints, but that's just my experience.
i think that, as long as you don't put too much into the smile line, even expression lines get better with filler. the key to natural results is that you don't put too much in. i use juvederm there and get good, consistent results. botox around the mouth is a good idea, but the 2 units for the smile lines i do not like doing because it can drop the top lip down a bit.
both juvederm and restylane will encourage collagen growth. i like juv. a bit better because it seems to last a bit longer, you can inject it deeper, so there's less of a blue streak effect and it tends to lump up less. for a longer effect, i would use juvederm ultra plus.
hope that helps

Sun Damaged Skin - Phenol vs Lasers

hi, I really have some questions and I am going crazy cause I just don't know. I am 25 and I tanned alot when I was younger mostly 14- 18. When I was 21 I noticed a fine line on my forehead and I freaked out. Since then I have been using sunscreen and never tanning. Now I have rough skin and large pores on my cheeks next to my nose and my forehead is not looking as good as it used to. My question is will i continue to age faster than those who did not tan as much or if I take care of myself and protect myself from the sun will I just go from here. i'm really scared. One more question. I have been looking into the chemical peels and have read a ton about them. While the tca seems more for like my skin type the phenol appeals to me much more because it is permanent but then again it can be scarier because of that. Will the phenol peel make my skin look unnaturally white and are there alot of complications to this. Does it tend to scar alot. Do you know what the percentage is of phenol peels that go smoothly. Thanks so much

hi,
don't worry about what you've done in the past. just take care of your skin from now on and you should be ok. use strong sunblock and reapply often if you're outside. use a moisturizer and a good cleanser. even if you have pores that are a bit big or a few fine lines, you will be able to take care of these with peels or lasers. tca is a good peel and you can adjust the strength of it to the person. phenol is usually quite harsh. i would stay away from phenol. if you need something that intense, i would go for lasers.
its not a question of permanent vs. temporary. all of the peels and lasers are permanent, its just that they can't stop time. its a question of intensity and precision. i think that lasers like active fx or fraxel are more precise and controllable.

Sculptra for Under Eye Dark Circle Correction

What about sculptra? It's so similar to juvederm or restylane, but made of a different kind of acid, and lasts a bit longer. Yet, I've read it does the same thing with collagen. I'd love to get your opinion.


hi,
i do not think that sculptra is such a great idea.
we already are getting a year and a half with juvederm - i don't think that sculptra is going to give us that much more duration. the other issue is that sculptra is not a filler - it is a collagen stimulating agent. it gets your own collagen to grow in the area where you inject it. the trouble is that it is a thin liquid, so the injector cannot be too precise with the location of the injection. under the eyes, every millimeter counts and juvederm / restylane is much more precise.
hope that helps

Restylane vs Radiesse for Non Surgical Rhinoplasty

Do you think Restylane is easier to inject in that it stays where you actually place it as opposed to Radiesse. I know Radiesse lasts longer, but I have heard that it is tricker to inject because it doesn't always stay put. Which filler is better for that?

Thank you


hi,
well, it depends on what you want to do.
restylane doesn't have alot of structural strength, so if you're trying to straighten out a droopy nasal tip, radiesse is the only one that is strong enough. camouflaging a bump on the bridge is ok with restylane, though, for example.
they are both maleable, and i have not had any problems with radiesse moving where i didn't want it to move. it takes alot of pressure to move radiesse around.
hope that helps.

http://www.westsidemedicalspa.com/non_surgical_nose.html

Active Fx vs. Fraxel Re:pair for acne scars

Dr Rvikin

I am also considering the Fraxel Re:pair, and weighing the difference between it and Total FX. I am interested in acne scars and have had dermabrasion and CO2. I understand the Re:pair goes deeper than the FX, but I don't quite understand the principle that if it promotes collagen why that would help reduce an acne scar. ie if you had a dimpled piece of fabric and put a flat piece of fabric under it the top layer would still be dimpled.


hi,
the depth of penetration between the re:pair and the Fx is not significant in terms of making a treatment difference. they are essentially the same technology. the way they work is by punching thousands of microscopic holes into your skin. the surrounding tissue is unharmed and helps with healing. each of those little holes heals into a more normal patch of skin, so you have thousands of little pixels of normal skin making your skin look smoother.
the collagen stimulation works like a foundation under the skin, making it firmer and giving it support. one of the reasons why acne scars are indented is that they have lost support and have caved in.
hope that helps.

http://www.westsidemedicalspa.com/activefxlaser.html

Artefill Migration and Restylane Collagen Stimulation

Dr. I recently asked you a question on Artefill possibly causing irritation. After doing some research I found that it is possible for the Artefill to not only migrate but there have been some reactions to the product up to 12 years later where the body slowly starts to reject the product. What are your views on that? Also, as I was researching I found that sometimes collagen formation can be stimulated after using restyline in a certain area after multiple uses. If I was to have restyline inject in a divet in my nose repeatedly could it have a cumulative effect where I wouldn't have to have it done so often? After reading that research I've become very fearful of the Artefills long term effects and the possible migration.

Thanks so much



hi,
its a very important question.
long term migration of filler is a real concern after the nightmares we saw with silicone.
i think that the migration reports you're talking about with artefill are actually about an earlier, less refined product that was used a long time ago in europe called artecoll. the fda approved version (artefill) has not had migration problems or granuloma problems because the beads are much smoother and more uniform in size. i have been using it now for over a year on a daily basis, and i have not seen a single serious problem. the only issues have been occasional temporary redness and need for touch ups.
collagen formation does seem to happen after restylane and juvederm and yes, as a result, even when the material disappears some of that collagen is still around as a cumulative effect.
hope that helps

Thermage vs Facelift

I am 55 years old and instead of a face lift I was considering having this non surgical procedure "thermage" for my face. I only have fine wrinkles. I would appreciate if you could tell me what are the advantages and disadvantages.? Are the results long lasting?

Thank you,


hi,
i have thermage, and i like the device, but i only recommend it for very specific things. i have not been extremely impressed by its results for full face treatments. what i do like is the results for the jawline / jowls area - it is subtle, but pretty good. afterwards the jawline definition is better, the area under the chin is tighter and the jowls are less prominent. assuming, of course that the jowls are minor. thermage will not be able to affect significant jowling. i do not think that thermage can be anywhere near a substitute for a face lift.
for fine wrinkles, i would suggest active fx / deep fx instead of thermage. it is more downtime (about a week), but the results are much better, in my experience. the active fx also improves pigmentation, pore size and will help with fine lines around the eyes.

Sculptra Lumps

Dear Dr. Rivkin,

I had SCULPTRA in my cheeks 4 weeks ago. The swelling went down and I look like before. I was told I would see a difference after the first time but unfortunately I dont:(
I was also told I might need one or even two more sessions but for now I don't know if I should spend a lot of money again while there is no difference at all and my cheeks look so thin:(

p.s. Is it still too early to see a growth difference or am I just out of luck?
Thank you


hi,
it sounds like you were not very well counseled about sculptra.
it is actually a good volumizing agent that works well, but people need to understand how the process goes.
it is a long road.
sculptra is not a filler and that is something that people need to understand. it is a collagen stimulating agent that works to grow your own collagen over time.
you may not see much after the first session, however it is after the second session that you will see a real difference. assuming, of course, that they are using a good ammount of sculptra - at least one full bottle for both cheeks.
There should be a month between the first and second sessions. You may need a third session, depending on the extent of the volume loss.
The benefit is that the effect is very natural looking - it is your own collagen, after all, and it lasts for at least 2 years, in my experience.
hope that helps


http://www.westsidemedicalspa.com/sculptra.html

Restylane vs Juvederm vs Artefill for Non Surgical Rhinoplasty

Hi Dr. Rivkin, I have a couple of questions.
WHen i went in for a free consultation, you said there was something for 800 dollars that would last for about 6 months. What was that again. Also, after that procedure you said I needed to come back within 3 weeks. From the time I get the procedure to my follow up session in 3 weeks, how much will the nose change?

Also, you said there was a catalyst to take the filler out (the one that lasts 6 months) If i like the procedure, can I take the filler out with this procedure and replace it with the permanent filler. This is because I do not live in LA and it will be more convenient if I can get these done whenever I have to be in LA. Thank You.


hi,
the 6 month filler is restylane or perlane or juvederm.
i usually see people back about 2 weeks after the first injection, although if you're from out of town, that is flexible.
the changes in the first 2 weeks are variable - with some people it doesn't go down very much and with some it does and we need a significant touch up.
sure, that is fine to dissolve the HA with enzyme, but i think what makes more sense is to use artefill at the touch up visit. you will need another touch up anyway, and this way within 1 to 2 visits after the first touch up, we can have the permanent effect.
those visits would be separated by several months, of course, as the perlane or restylane underneath the artefill dissolved.


http://www.westsidemedicalspa.com/non_surgical_nose.html

Botox and "Lazy Eye"

I recently moved to New York, and have had Botox previously with great results. But on my first visit to a new doctor, I got “lazy eye.” Did the doctor do something wrong? I told him where I had been injected before.




"Lazy eye" can mean one of two things, both of them representing an error in injection technique on the part of the doctor or nurse. It could be that too much Botox was injected into a low point on one side the forehead and weakened the forehead muscle excessively. This can cause a sensation of heaviness of the brow and it can look like the skin underneath the eyebrow is heavy and low on one side. This is annoying, but it does tend to go away within a few weeks. This problem can be avoided by being conservative with Botox injections in the forehead. I routinely use 12 units instead of the Allergan recommended 16. I very rarely get the heavy eyebrow problem and my patients are very grateful that they do not have the paralyzed Nicole Kidman look. It pays to go to an injector who is experienced enough to avoid this issue.

The second possible meaning of "lazy eye" is more serious. It is when the Botox was injected so close to the midpoint of the eyebrow that it affected the muscle that keeps the eyelid elevated. The result is a partially closed eyelid for several months. This happens rarely. Ideally, it should never happen and is usually the result of a combination of unusual patient anatomy and a serious error in injection technique by the doctor. There is an eyedrop called Iopidine that helps somewhat. Fortunately, everything goes back to normal within a month or two.

The lesson here is: Know your injector!

Botox injections are really easy, effective and safe but there is always a possibility of side effects, especially in the wrong hands. Go to someone experienced, someone recommended and someone in a physician's office (i.e. not a mall, or someone's house or in the back of a facial salon). You want to know that if something does go wrong, there is an experienced doctor ready to fix you up.

Fraxel Re:Pair and Active Fx Safety and Preparation

Dr. Rivkin,

I am consdering undergoing Fraxel re:pair. What is the differnece between this and the Active FX laser that you offer (they seem rather similar)? What are the possible side effects of such a procedure? How common is post-procedure hyperpigmentation? Thanks.

Amy



hi amy,
they are very similar devices - both are fractional CO2 lasers. the technology is good and both will give you good results. i got the active fx because the re:pair is such a new device, i hate being the first one to try something that just comes out. although reliant is an excellent company and has done all sorts of testing and refinement on the technology, this is the most invasive laser we have for use in the office. i want to be absolutely positive that it is perfectly safe. active fx has been out for a couple of years and has had great results without problems. so i felt safe getting it.
that being said, the re:pair has been out for a few months now, and i have not heard of any problems with it, so that is encouraging. your doctor will probably be the best person to speak to you about the re:pair in detail.
hyperpigmentation is higher in asians, as well people who have darker skin( hispanic, middle eastern, indian and black). i would be extremely careful if you fall into these categories. make sure that your doc is pretreating you with topical bleaching agents for 2 weeks. also, you have to be very careful of the sun before and after your treatment.
you should go on antivirals beforehand and antibiotics afterwards to make sure you do not wind up with a skin infection. you are compromising your skin protective barrier, so bugs can get through easier.
hope that helps