Despite the cold temperatures of January, Spring will be here before we know it as we brace ourselves for summer and bare more skin. Cellulite is an extremely common condition that affects women of all shapes and sizes. It develops when fat cells protrude through the thin fibrous connective tissue that exists between the skin and the underlying muscle. With age, sun damage, and weight fluctuations, dimples and depressions in the skin will reveal more surface irregularities no matter how thin a person is. In order to correct cellulite, the fat must be reduced and the fibrous tissue that creates the dimpling in the skin must be loosened to enable the skin to appear flat and smooth. The skin must then be tightened.

The VASERsmooth procedure accomplishes all of these things with one device. Other treatments currently on the market such as Endermologie, Accent RF (a radio frequency device to tighten the skin), Elixis, Thermage as well as Coolsculpt to reduce the fat, only attack a single aspect of cellulite. VASERsmooth is designed to melt superficial fat, break the dimpling fibers, and tighten the skin. It is a one-time treatment performed under local anesthesia in the office. Patients can return to work the next day and results can be seen in as little as 2 weeks. Its main competition is the slightly older Cellulaze laser which is a revision of the Smartlipo device. Unfortunately, we have found the Cellulaze laser to lack in potency, safety, and efficacy compared to the ultrasonic energy in VASERSmooth. This is the hot new technology that is for the first time delivering significant and consistent results in the battle against cellulite. Go to www.pfrankmd.com to find out more about this exciting treatment.

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Just when you thought the acne of your teens and 20s was over, a sudden outburst of pimples and breakouts is wreaking havoc on your skin unexpectedly in your 30s and 40s. As hormones begin to shift in a woman’s 30s, it is common to experience changes in the skin including pigment and acne. Hormonal acne is frequently concentrated on the lower part of the face around the chin and jaw line. Facial hair often accompanies hormonal changes which can add fuel to the fire creating infected hair follicles as hair will often grow in thicker particularly around the chin.

Fortunately, there is a protocol of care to help treat this condition beyond conventional therapy of oral anti-biotics, and topical medications. One prescription medication in particular called Spironolactone is most successful in treating hormonal acne. Spironolactone is actually a blood pressure medication which in smaller doses is proven to successfully treat hormonal acne by blocking the androgen that stimulates the production of excess hormones which produce acne. Occasionally, a routine blood test may be ordered to confirm a hormonal imbalance. While Spironolactone can take 4-6 weeks to work, it will reset one’s hormones, which in turn solves the acne problem.

Once hormonal imbalances are in check, reducing the hair permanently will reduce the breakouts so that hair follicles do not get infected leading to cystic acne. Within 4-6 treatments of Laser Hair Removal, hair is removed permanently. Fraxel Laser treatments are also beneficial as it reduces the pore size, which affects acne as well as reducing pigmentation. With the appropriate course of action and awareness of when and why acne is occurring, skin can remain clear and free of change during the time when the rest of the body is not.

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So it has been a few years since the Ulthera device has been released and currently it remains at the top of the heap in technologies for facial skin tightening. That position was not without compromise, to some degree, as the procedure traditionally was considered very painful. My use of the device over the last few years has been successful, but regularly required some form of sedation in the form of Valium, Demerol or a combination of the two. I am happy to report that upgrades in the system, personal experience, and some recent clinical studies have markedly improved the experience of the Ultherapy treatment both in comfort and efficacy. We have been performing Ultherapy using many more passes at slightly lower settings and getting excellent results on a wider range of patients. This has made the procedure far more tolerable and effective for my patients as this procedure continues to become more and more popular. I look forward to the continued progression of this technology to other indications and body parts.

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September is here and you may find that despite the warmth and strength of the sun, the air is suddenly different. Crisp Fall days are coming and that means that as the drier air moves in, skin is going to change and react even while our faces are still freshly sun kissed. For some, dryness increases while others experience acne flare-ups. For those with Melasma, this is a welcomed time when Melasma inflammation decreases as the heat of the summer dissipates.

The Fall is the best time to clean up one’s skin and while it can be challenging to keep a balance of moisture, the good news is that keeping it simple is the best way to go and that goes for one’s makeup and skincare regimen as well. The cosmetics and cosmeceutical industries today are as changing as fashion- new color palettes, textures, foundations, lotions and potions submerge the market. My best advise- Wait. Treat your skin first before introducing anything that will irritate, breakout, or aggravate pigment on your face. This time of the year more than any other is ideal to keep your face fresh with minimal products, especially makeup. Keep to your routine and whatever you choose from an arsenal of products, use it and use it consistently. There is no magic wand, only a commitment to taking care of your skin.

Any small change will aggravate skin. With the latest trend in makeup being a “flawless” complexion, it is most challenging to keep a natural look. Makeup is meant to enhance not cover. The Clear & Brilliant treatment remains the most popular treatment to even out skin and rid of excess pigment. A fractional laser treatment, Clear & Brilliant evens skin tone by treating below the skin’s surface without leaving the top layer of skin exposed and susceptible to outside damage the way peels and other topical acid treatments can. With minimal downtime and a commitment to regular treatments, patients find that they can wear less makeup, which means less irritation and breakouts from products as they try to ‘cover’ rather than ‘treat’ the problem.

Treat your skin well and it will be your best fashion accessory this Fall.

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Although it is not a typical time for new technologies as the summer is in full swing, a simple new device has caught my attention and is worth discussing. Dermapen is a novel technology that manually resurfaces total body skin that may replace other non laser techniques such as subcision, punch grafting, CROSS technique and rolling micro-needling devices. Unlike micro needling rollers, the Dermapen uses a spring loaded, stamping technology where the skin is rapidly pierced at ninety degrees at a designated controlled depth. The device provides uniform, fractional micro wounds in the skin that stimulates healthy growth of new tissue without the heat trauma of lasers or other devices. What is great is that it can be used on all skin types. When utilized for mild generalized resurfacing of the face, products such as topical growth factors and anti-ageing serums are better absorbed in the skin for increased efficacy.
Due to its ergonomic penlike design we can treat the whole face or very small areas that cannot be accurately targeted by larger devices – the sides of the nose and the lower and upper lip, areas where scars and wrinkles are traditionally difficult to treat.
In general, I am using the device to treat acne scars and fine lines. The Dermapen will create tiny holes in the tissue and set off a healing cascade that will encourage the development of new blood vessels and growth factor release. The micro needling process will also force the body to manufacture collagen and elastin. How the treatment is performed varies significantly. I do recommend a series of treatments that can range in number and recovery time depending on each individual’s case. Recovery can be as little as 1 day or as aggressive as a week. Anesthesia may include topical or injectional therapy.
The Dermapen is also useful in the removal of stretch marks, particularly for darker skinned patients where lasers may cause hyperpigmentation. This device should work as a good adjunct to the Vbeam & Fraxel lasers for this purpose. A nice plus is that I can always combine Dermapen with other treatments safely. I am enthusiastic to add this device to the repertoire of treatments this fall. http://www.pfrankmd.com/dermapen.html

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Its Spring time…Turn a page of any beauty and fashion magazine in the last month, and chances are you have seen every cosmeceutical product and technology on the market claiming to treat any cosmetic concern on the face and body. As we approach the summer months preparing to bare more skin, cellulite is one of the most common complaints amongst women. For decades, the industry has sought to find a cure for cellulite, a dimpling of the skin, which can be caused by several factors including diet, stress, and genetic predisposition in particular. While numerous technologies exist to treat cellulite, none have proven to have a long lasting effect.

Cellulaze is a device produced by Cynosure, the makers of Smartlipo, and has gained much media recognition recently. This “new” technology is a surgical procedure and uses a laser fiber to break up or ‘subcise’ the connective tissue under the skin that causes cellulite while tightening the skin. This technology is similar to the Smartlipo device which is used for liposuction; A device that breaks up and removes the fat while tightening the skin. Cellulaze treatments can range from $2,500-$10,000 depending on the areas treated. In my opinion, the present Cellulaze technology offers no long term resolution for a problem that is difficult to treat while warranting the cost of the procedure.

Thermage continues to be a successful option for tightening the skin. Used In conjunction with fillers and subcision, cellulite can be corrected and maintained. For larger areas of cellulite and fat removal, liposuction remains a more long term option for evening out the skin. While I am hopeful that technology industry leaders will offer a more permanent option to treat cellulite, at the moment the cost-benefit ratio is not enough to promote Cellulaze as the end all for cellulite.

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Wrinkle fillers have come a long way in a very short time. Hyaluronic Acid (HA) wrinkle fillers such as Restylane and Juvederm remain the most popular as they offer versatility and reversibility. Merz Aesthetics, the makers of the deeper dermal filler Radiesse is approaching the release of Belotero, the latest HA that is best for fine lines. I am proud to be one of the first physicians in the country to be using Belotero.

The most exciting component of Belotero is that it can be used to treat the fine lines throughout the face, neck, and chest that Botulinum Toxins (Botox, Dysport, Xeomin) and laser are hard to treat. Fine lines above the lip and around the mouth in particular are vanished. The difference is not only the composition of Belotero, but the actual technique of injection which is performed more superficially reducing the possibility of a “tyndell effect” (a darkening of the skin or blue hue) which other HA products can create if not injected properly. This quality makes it ideal to use under the eyes (tear troughs) in particular and around the mouth.

The Fraxel Dual and Repair remain the gold standard of technology for diminishing the appearance of pigment on the face, neck, and chest. While Fraxel Repair resurfacing treats fine lines, there is significant downtime and cost associated with the procedure and not everyone is a suitable candidate. In an effort to create an overall appearance of rejuvenation, Belotero is a unique option and I feel confident that it will have a significant place in the palette of options that I currently offer in my practice.

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Melasma is the number one concern of my female patients. If the spots on your face that you thought were freckles are now larger clusters of irregular patches on your cheeks, forehead, or upper lip, chances are you have developed melasma. One day you don’t have it, the next day it suddenly pops up leaving you frustrated. One patient described it as, “trying to prune a field of weeds”, it keeps coming back. Chances are, if you are in your 20s and 30s, have a more olive complexion, and have sun damage, you have developed melasma or will most likely have it at some point in your life. So, in an effort to clarify the many options for treatment, I would like to address the most successful treatment protocol and maintenance which have kept my patient’s melasma free.

It is known that the main causes of melasma are hormonal imbalances and can be exacerbated by changes in estrogen levels caused by oral contraceptives, and pregnancy (known as ‘the mask of pregnancy’). Diet, exercise, and stress also play a critic role as an imbalance of any of these can wreak havoc on a woman’s hormones. Therefore, anyone can get it even if you are not pregnant or taking birth control. The challenge for many women is to maintain clarity and choose from the numerous skincare products and treatment options. As the warm sunny months approach, melasma is challenging to control as even the slightest bit of sun exposure or heat will cause an outbreak. Following an outbreak, it takes a diligent commitment to treatment and maintenance to get the skin back to normal.
The days of hydroquinone based products and AHA’s, alpha hydroxy acids (such as glycolic, lactic, kojic and azelaic acids), have been surpassed by products containing Arbutin and lignin peroxidase, a natural derivative from mushrooms. Earlier treatment protocol consisted of acid peels and high concentrations of hydroquinone such as Cosmelan leaving the skin in a sense ‘open’ and ‘raw’, making it more susceptible to environmental damage from sunlight, pigmentation, as well as thinning the skin.

Fractionated technology remains the best treatment protocol to reduce the pigment caused by melasma in my practice. The Fraxel Thulium (http://www.pfrankmd.com/thulium.html) and Clear & Brilliant treatments (http://www.pfrankmd.com/clear-brilliant.html) reduce the pigment at the source without damaging the top layer of skin. While there are often questions about skin color, and post inflammatory hyper pigmentation, it is important to be treated by an experienced laser surgeon. Following treatment, a daily regimen of spf 15 or higher moisturizer is essential as well as a product to maintain clarity. Elure™ (http://www.pfrankmd.com/elure.html ) is the latest and greatest product on the block which breaks down excess melanin (pigment).

Used daily, skin is kept clear and unlike hydroquinone and AHA’s will not make the skin light sensitive. Depending on the severity of a patient’s melasma, a product containing Arbutin or kojic acid may be added to the treatment protocol, short term, to inhibit the production of the enzyme tyrosinase which produces melanin. The goal is to reduce the existing pigment while preventing it from reproducing. With the right course of treatment and daily skincare maintenance, you can put your best face forward. For information on treatment for melasma please visit www.pfrankmd.com

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Hyperhidrosis is a surprisingly popular condition in dermatology practices. With the advent of Botox injections as a overwhelmingly successful treatment for localized areas of excessive sweating, the prevelance of this condition has become more apparent. Often found in young adults, Hyperhidrosis most commonly occurs on the underarms and hands and feet. Occasionally, individuals experience the problem all over the body causing significant psychosocial debilitation. In addition, the excessive sweat functions as a skin irritant causing a long list of rashes that effect the health of the skin.
Several treatments do exist that range from prescription based topical antiperspirants to oral anticholinergic therapy to more extreme measures such as surgery- a treatment that does carry some degree of risk and side effects. The most popular treatment which seems to only work for localized areas, is the injection of botulinum toxin, or BOTOX. The drug has the unique ability to stun sweat glands locally without any side effects or rebound sweating elsewhere. It is easy, safe, but expensive. Insurance companies ocassionally pay for the treatment, but coverage is becoming less frequent and is difficult to get. A large percentage of patients still pay out of pocket which can cost up to 1800-2500 dollars a year (twice a year treatments).
As a more permanent option there is a localized surgical treatment that works only on the armpits. Under local anesthesia, a small ultrasonic wand called VASER is run under the skin through a small incision and can be used to kill the sweat glands without any significant risk. Treatment is performed 1-2 times with long term efficacy. I have been performing this technique for several years nowand patients are happy. But , new technology has come out which may be more simple. Miradry- is a device that uses microwaves to destroy superficial sweat glands. It is a nonsurgical treatment that involves injecting anesthesia and then passing the device over the area. Two treatments are preformed at 4-6 week intervals and results have been significant and long lasting. Recovery is like the vaser treatment with a few days of mild soreness and bruising . The limiting factor of all these treatments is cost. Unfortunately, like most cosmetic treatments these surgical or device oriented treatments are not at all covered by insurance and can cost about 4500 dollars for the completion of the treatments. Hopefully with the increasing prevalence and efficacy of new treatments we will see the cost improve as well. Please refer to our website for more details. www.pfrankmd.com

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With fractional resurfacing being clearly the most popular treatment over the past 1-2 years, patients are seeking procedures with the most limited downtime to accomodate their busy lives. Although there will always be some degree of ‘no pain, no gain’ to laser treatments, technologies are certainly maximizing results with limited recovery. Recently the developers of Fraxel released a fractional device called Clear & Brilliant. Although not as clinically dramatic in results as other Fraxel devices, the technology uses a novel wavelength of light that minimizes peeling during recovery. From our experience thus far, the technology benefits younger patients with limited amounts of sun damage or more advanced patients who are looking for no downtime maintenance to other procedures they have done in the past. The treatment takes about 15 min and produces mild redness that lasts only a few hours. Makeup can be applied immediately and the skin will feel dry for a few days only. Thus far, Clear and Brilliant seems like a very promising minimally invasive treatment for overall skin rejuvenation. Although the results are not as dramatic as other Fraxel procedures, it will certainly fill a much needed niche in the field of laser resurfacing.

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