Noninvasive surgical interventions are widely used to stave off the effects of aging on the skin. These products and procedures represent a billion-dollar market in today’s youth-focused society. People are living longer and staying healthier and active longer, and they want to look as good as they feel. Which specialists are best positioned to offer procedures for sun damage, pigment changes associated with aging, baggy skin, sagging cheeks, wrinkled necks, purse-string lips, and frown lines around the mouth or eyes?
Most of these procedures were not taught in medical school. We learned about them post-residency. In my view, the specialists who are best suited for doing these procedures include the Quad Four: dermatologists, ophthalmologists, otolaryngologists, and facial plastic surgeons, said Jean Carruthers, MD, an ophthalmologist who is trained in all the procedures discussed in this article. Dr. Carruthers is Clinical Professor of Ophthalmology at the University of British Columbia in Vancouver, Canada, and she is Medical Director of Carruthers Cosmetic Surgery in that city.
Anyone who is well trained and credentialed can do these procedures-and that includes dermatologists, ophthalmologists, otolaryngologists, and facial plastic surgeons, agreed Wayne Larrabee, MD, who is Director of the Larrabee Center for Facial Plastic Surgery in Seattle.
ENT Today spoke with Dr. Carruthers, Dr. Larrabee, and Jenifer Henderson, MD, who is an associate at the Larrabee Center, about the role of different nonsurgical interventions to address aging skin.
According to Dr. Carruthers, the two most important types of topical agents for treatment of sun damage and pigment changes are vitamin A creams and sunscreen creams or lotions with a high sun protection factor (SPF).
Vitamin A creams do three things: reduce the amount of pigment; reduce the amount of oil secretion; and restore collagen into the skin. Creams like Retin-A™ [tretinoin] and Tazorac™ [tazoratene] should be used daily; however, they dry the skin and can be irritating, so they should be used according to tolerability. she said. Retin-A is one of several commercial tretinoin creams available in the United States, which are indicated for fine wrinkles, dark spots, sun damage, and rough skin.
Dr. Carruthers believes that more is better regarding the SPF level in sunscreens. Why wouldn’t you want as much protection as you can get? said Dr. Carruthers. She recommends using a daily sunscreen with 60 SPF.
Dr. Larrabee and Dr. Henderson say that a sunscreen with 30 SPF is adequate for most people. Sunscreen should be applied to the skin repeatedly throughout the day. They both recommended Anthelios ™ SPF 30 as a good choice.
The best sunscreens contain a number of ingredients to block UVA, Dr. Carruthers said. These are Parsol 1789, titanium dioxide, avobenzone, and mexoryl. UVA radiation can penetrate windows-car windows, windows at home, windows at work. In addition, people need to know that only 10% less UVA comes through on a cloudy day. Hence, there is the need to wear sunscreen throughout the day, whether indoors or not, and to reapply it during the day. Also, Dr. Carruthers advised being prudent about sun exposure, and wearing a hat between 1 and 3 PM when outdoors.
Responding to concerns about people who wear sunscreens not getting enough vitamin D to maintain bone health, Dr. Carruthers commented that 15 minutes a day of sun exposure should fulfill the vitamin D requirement. People who are fair-skinned should be cautious about sun exposure during the heat of the day, however.
There are a thousand other topical agents for sun protection and antiaging, but most of them have more marketing than science behind them, she stated.
-Wayne Larrabee, MD
Another product Dr. Larrabee and Dr. Henderson recommended is Remergent™, which promotes repair of DNA sun-induced injury. We use vitamin A derivatives, hydroquinone, glycolic acids, and sunscreens, and tailor these agents according to the problems, such as sun damage, wrinkling, pigment changes, and thinner, dryer, skin that has lost its elasticity, they said.
Botox and Fillers
New evidence suggests that as people age, they fall into patterns of facial innervation that affect the lips, brows, and other parts of the face. Repetitive movements due to changes in facial innervation lead to changes in the skin, creating either wrinkled brows, frown lines, or purse strings around the lips. These are called dynamic changes.
Botox™ [botulinum toxin] is one strategy to address dynamic skin changes; Botox lifts and recontours the brows, gets rid of frown lines and purse strings around the mouth, and lifts sagging segmental skin in the neck
Botox makes people look 10 years younger, Dr. Carruthers said.
Botox may be sufficient to restore volume and help wrinkles for younger people, but for women in their 40s and 50s, Botox should ideally be joined by a filler, Dr. Carruthers continued.
Volume depletion occurs with aging, and this is not just due to reduced fat cells, but also to bone loss. The maxilla rotates inward with age, and bony mass in the chin decreases. Put this together with reduced fat and sun exposure, and you have a strong aging effect visible with the changed draping of the facial skin, Dr. Carruthers said.
One way to describe the effects of aging on the skin in relation to the bone and fat changes that occur is that the tablecloth is too big for the table, she continued. The skin on the face slowly and inexorably sags.
Typically, we use Botox and injectable fillers together. Botox treats the dynamic action of the muscles and relaxes them, preventing creases from getting deeper. If the crease is severe, we use Botox plus fillers, Dr. Henderson commented. Dynamic wrinkles respond to Botox, whereas sun damaged skin requires fillers and resurfacing.
In the past, surgically placed implants were used to plump up areas such as the chin and the cheek. The downside of implants is that they are palpable and sometimes become visible over time. Also, they are delicate to place.
Implants are not ideal, because even after you place an implant, the aging process continues. Now we augment surgically placed implants with injectable fillers, Dr. Carruthers said.
-Jean Carruthers, MD
Injectable fillers give excellent results for folds and wrinkles on the face, depressed mouth corners (marionette lines), sunken under-eye folds, and other frown lines, Dr. Carruthers said. One advantage of using injectable fillers is that patients can watch the procedure and participate by responding to the effects. Usually, injectable fillers need to be repeated every five to eight months. Another advantage of fillers is that that they work right away, whereas Botox takes two to five days for the full effect to be visible. Injectable fillers that are good for superficial procedures include hyaluronic acids such as Restylane™ and Juvederm™; Juvederm Ultra Plus™ and Perlane™ are preferred as deeper fillers. These fillers are made from naturally occurring substances and are very rarely allergenic.
The neck can be lifted by injecting filler along jaw lines, restoring a youthful look Other fillers are available. Evolence Classic™ is a porcine third-generation collagen that Dr. Carruthers called a wonderful product. It is cross-linked with sugar, which makes it difficult to break down. It also is less likely to cause bruising than hyaluronic acid products. Up to 50% of patients who are treated with hyaluronic acid products have bruising, she said.
Volumizing fillers for cheeks and chin include Juvederm Ultra Plus, Perlane, and Radiesse®. Radiesse is a longer-lasting filler, which is not permanent, but achieves good results for volumizing cheeks and the chin (not for lips). For the lips, Dr. Carruthers prefers Restylane, Juvederm Ultra, and Evolence™ Breeze®. Evolence Breeze is less viscous than Evolence Classic and lasts much longer, she said. Evolence products received FDA approval June 30 for use in the United States.
The only absolute contraindication to injectable fillers is allergy to any of the components. Patients who are not sure what kind of end result they want are also not good candidates for injectable fillers. However, with hyaluronic injectable fillers, people can change their minds and reverse the procedure with hyaluronidase, an eraser of sorts. If the patient doesn’t like the result, he or she can come back and get rid of it. You could think of the first procedure as a rehearsal, Dr. Carruthers said.
Botox treatments are given every three to six months. Fillers are given every six to 12 months, depending on the type of filler used and the area injected. The cost of Botox and fillers varies according to the type used and the areas treated.
Safety of Botox
Despite recent warnings by Public Citizen about therapeutic uses of Botox in children with cerebral palsy, Botox is incredibly safe for cosmetic procedures, Dr. Carruthers said. Cosmetic doses are at least 10 times lower than the doses used for cerebral palsy. Only one death has been reported in a patient treated with cosmetic Botox, and that death was due to methicillin-resistant Staphylococcus aureus (MRSA) pneumonia-unrelated to Botox.
Dr. Larrabee said that Botox has a minimal risk of allergy-and most injectable fillers rarely cause allergies, because they are similar to natural substances produced by the body.
-Jenifer Henderson, MD
Dermabrasion has largely fallen out of favor at Dr. Carruthers’ clinic. It is no longer legal to give the Freon gas to stiffen the skin for dermabrasion, she said. The field is shifting toward lasers, which are safer and do not cause blood splatter, which is important in this age of contagious blood-borne diseases such as AIDS and hepatitis.
Dr. Larrabee and Dr. Henderson agreed that they do not use dermabrasion as much as in the past, but said that it is useful for scars, pitted skin from acne, and after Mohs reconstructive surgery. It is rare for anyone to perform a full-face dermabrasion, Dr. Larrabee said.
In addition to being safer than dermabrasion, laser treatment allows more precision and is more predictable for skin resurfacing. This treatment is suitable for all patients who want skin resurfacing. You can precisely set the depth of the laser to address pigment changes, severe wrinkles, or a combination of the two, Dr. Henderson said. You can tailor it to what the patient wants to achieve.
Contraindications to laser resurfacing include dark skin, keloid or hypertrophic scarring, and use of Accutane™ within the past year. In Dr. Larrabee’s opinion, laser should not be used to tighten neck skin. He said that sagging neck tissue should be treated with a face lift, not a laser.
All patients who undergo laser surgery should be pretreated with an antiviral agent to prevent oral herpes reactivation. The skin should also be pretreated with a bleaching agent plus Retin-A to reduce pigment problems and speed healing, Dr. Henderson added.
Dr. Carruthers said that two forms of the Ultra Pulse Encore™ pixilated carbon dioxide laser are useful for cosmetic procedures to tighten baggy lower eyelids; unlike Dr. Larrabee, she uses this type of laser for loose skin on the face or neck. The Deep Fx laser head of the Ultra Pulse Encore is used to tighten tissue and has an advantage over older lasers because of pixilation, which spares more normal tissue and speeds healing. At the most, five to seven days of rest are needed to recover from skin-tightening procedures. The Active Function utilizes the same pixilation and is carbon dioxide-directed; this is used for more superficial procedures, like a deeper intense pulse light, Dr. Carruthers said.
Recovery time following laser resurfacing depends on the depth of the treatment. A minimum of five to six days is needed; for deeper procedures, it takes about 10 days to recover and skin redness may persist for a few weeks to a few months.
Laser resurfacing is usually accomplished in one session. The cost varies according to the depth of surgery and the type of anesthesia required, and can range from $2000 to $3000 for a full-face treatment to up to $5000 for skin that has more sun damage.
Thermage and Titan
Thermage is also used to tighten skin on the face and the neck. The first type of thermage to become available used radio frequency as an energy source. More recently, Titan™, a technique that utilizes infrared laser, has become available. In addition to uses on the face, it is promoted for use on the stomach and thighs.
Both of these treatments target the deep layer of skin using a heating process to tighten pre-existing collagen and stimulate new collagen production. This technique is good for younger women with good skin elasticity who have early changes associated with aging, Dr. Henderson explained. Be aware that heavy faces don’t have as good results as thinner ones, Dr. Larrabee added.
Thermage treatment entails a series of two to four sessions, three to four weeks apart, followed by an annual treatment. The cost for the series is about $2000 to $3000, and all skin types can benefit from thermage.
©2008 The Triological Society