The treatment of leg veins has been around a long while. Depending on the size of the vessels there are various options from minor injections to laser to more aggressive vein stripping, surgical procedures. There is no best treatment because there are so many variations of leg veins. Recent innovations have improved treatments, though. Beyond the scope of my expertise are the improvements in the surgical approach that used to entail rather aggressive vein stripping in the OR under general anesthesia. Now with the use of radioablation and internal laser treatments, the treatment of vascular insufficiency and varicose veins has become a lot simpler and safer.
On the non-invasive front, which is my focus, there is sclerotherapy. A procedure that has been around for decades, sclerotherapy is still the standard of care for small red/blue spider veins that plague women throughout the world. Several agents have been used with various degress of success, pain , and risk. Salt water solutions are the most common agent to date. Recently the the FDA has approved for use- Asclera, otherwise known as polidocanol. It is a solution that has been used in Europe for quite a while that is far superior to other agents. First off, it is close to painless. Its safety profile is excellent and its has the ability to treat various sized vessels that we cater to with differing concentrations. As with other agents, sclerotherapy is often done in a small series of treatments and patients can return to full activity often right away. On occasion, stockings are used to help healing and treatments can be performed 2-4 weeks apart. Contrary to popular belief, external lasers are more expensive, have more complications and are less effective than performing sclerotherapy. For more details about the procedure feel free to peruse the site at www.pfrankmd.com. Have a great Thanksgiving!

So I just got back from one of our cosmetic society meetings in chicago and there are certainly alot of things to talk about. I did want to briefly address a topic that has been growing quit a bit. Non invasive nasal reconstruction is getting more and more popular. Using various fillers and botox/dysport we can alter the shape of the nose. Although it is certainly no replacement for nasal surgery, using these non invasive techniques certainly supplement the process. The simplest treatment is performing a slight lift in the nasal tip, which is a common complaint, with botox or dysport. By relaxing a muscle that pulls the nose down over time we can accomplish this. Unfortunately, it does take maintenance. Using fillers such as juvederm, restylane, and radiesse we can smooth out some bumps and reshape some asymetries that exist in the nasal structure. This is very common after nasal surgery where the result may not have been ideal. Nose job surgeries, like many cosmetic surgeries, are not perfect and 100 percent predictable. Instead of undertaking an additional surgical procedure, these non invasive alternatives can be very useful to acheive the desired result. For a permanent result, silicone microdroplets can be used once a temporary filler establishes a satisfactory result.
Although this is now commonly performed, it is essential to seek out a medical professional that has alot of experience with fillers. These are advanced techniques and they do have aesthetic and medical risks. So in summary, the advances in fillers and toxins really have enhanced rather than replaced the surgical means in changing nasal shape. Depending on the desired result there are instances that surgery can be avoided but this is not always the case. Consultation with both an expert in nasal surgery and a cosmetic dermatologist with expertise in fillers is necessary if considering these treatments.

So i want to address an article that came out in one of the beauty magazines last month. It discussed the use of various fillers for the body as opposed to merely the face. I often get asked this question in my practice as it seems logical that if we can now sculpt and volumize the face that we can also accomplish this with the body. The fact is that it is possible but there are some logistical issues that often make it unrealistic. 1st off – most temporary fillers such as Restylane, Juvederm, Radiesse and Sculptra would be too expensive to use in significant volumes that would be needed for areas such as buttocks, breasts, hips etc. There are attempts being made with products such as Macrolane which is a hyaluronic acid fillers used in Europe for supposed breast enhancement. Unfortunately, its use is not very popular because it just does’nt compare to implants. You need to inject an enormous amount of it to get significant results and it is temporary. Implants are more consistent and natural appearing. There are certain instances such as body scars/defects and occasional deep cellulite pockets that I would perform body filling but it is not the norm. The most logical filler for body enhancement is one’s own fat. We certainly perform this in my practice. BUT…it is not common to find a patient who desires body fat transplatation to have enough donor fat from another area of the body. In addition, fat is not necessarily permanent either and would require several rounds of transfer to get enough fat to “stick” (this is true in the face as well). Fat transfer is most commonly asked about in reference to buttock enhancement…aka the brazilian butt lift. I do not perform this procedure because i have found in my own hands and also the results of many other physicians to be extremely inconsistent and often unattractive. The recovery is uncomfortable, the results often unnatural looking and most importantly too temporary to be worth the surgical procedure. There are some doctors that would disagree but most, including myself, believe that an implant is a more suitable option for buttock enhancement. So, pessimistic as it seems, i do believe that, as with all cosmetic technologies, we will see advancements in this arena. Although there are exception to the rule, i still believe that there are significant limitations in performing body volumization. I look forward to investigating, practicing, and writing about new options of treatment in the future.

I know I have written on this topic in the past, so I will limit my diatribe and refer you to earlier posts. BUT….the Wall Street Journal personal section had an extensive article on these technologies recently that has brought the topic of non invasive fat removal in the forefront again. Like most articles written about beauty, there was not full disclosure from those in the know! Point being-these technologies are NOT the standard of care for fat removal. Way too many patients are wasting valuable time and money trying to take off inches with these Zerona and Zeltiq devices. What the article did address, which is a valid topic, is that fat is a complex, very functionable part of our body in regards to metabolism, storing and dealing with toxins, and hormonal regulation. Hypothetically, if we can melt large amounts of fat non-invasively (which we cannot) what would the consequences on the body be. My impression is that it would not be the best thing for you. If you have garbage in your backyard- cart it out, don’t melt it down or burn it. The same holds true with fat. Liposuction, particularly Tumescent Liposuction performed solely under local anesthesia is still the safest and most effective method of fat removal hands down. The Zerona and Zeltiq technologies offer very limited amounts of fat removal, if any. Is there a future in these technologies- I do hope so. But for now, in my opinion, it is still science fiction. Unfortunately, 15-20% of my liposuction patients have already spent time and money on these or similar technologies. There were obviously not happy to realize the hard way that Tumescent Liposuction was going to be the only answer for them.

So what’s new? Well, new is not always better. In this case though, you can teach an old dog new tricks. Laser Hair removal is about 15 years old now. It has certainly come a very long way but it has also had it limitations. Still to date we cannot remove gray hair or very lightly pigmented hair. The target for hair removal laser is pigment. We have improved the manner in which we treat different skin types. We can certainly treat skin of color and we can treat various thicknesses and densities of hair. All this is very good to achieve the overall result of permanent hair reduction in most people. Until recently, laser hair removal, like most forms of hair removal, remained very tedious, time consuming, messy and often painful. This often deterred a large part of the population from getting it done, particularly men who have larger areas to treat such as backs and shoulders. One of the most recent advances in laser hair removal has come from the company that had the gold standard device in the past- The Light Sheer hair Laser. With the ability to treat all skin types with the least number of treatments necessary, this device has proven over the years to be the rolls royce of hair removal lasers. Their most recent prodigy is the Light Sheer Duet Laser. Using similar Diode technology the LightSheer Duet has two treatment heads-the traditional 9×9mm which is still great for small tough to reach areas and the duet HS or high speed hand piece which is almost 10 times the size at 22x 35mm. This allows for dramatically faster, deeper and more efficacious treatments. Backs and legs are done in 15-20 minutes as opposed to 1-1 1/2 hours. The device also uses what is known as pneumatic suction to draw the skin gently into the laser improving penetration of light, efficacy, and a dramatic reduction in pain. The overwhelming majority of patients no longer require anesthesia or treatment gel, making the treatment quick, clean and easy. Thus far i have nothing negative to say about this laser. A dramatic number of patients that would not have done the treatment in the past are coming into the office and leaving very satisfied. A large number of men are also being added to roster. Because of the speed, ease, and minimal discomfort treatment cost becomes more and more attainable as well. I do believe this is the new standard in Laser Hair removal. Feel free to watch a video about how the laser works on our website- www.pfrankmd.com

Stretch marks or striae are one of the most annoying cosmetic skin problems. The second runner up, cellulite, we will talk about another time. What is generally unknown is that stretch marks are common in men as well as women. They are basically a form of scar tissue where the elastic fibers of the skin are overstretched causing a very signature look with some variation in color and quality. Most popularly they come about during pregnancy. There are also very common during puberty during growth spurts. It is in this circumstance that young men often acquire them. In all cases, one’s susceptibility to them appears to have a strong genetic factor but obviously anyone can get them. The more trauma or stretching action to the skin the more likely one is to acquire them. Some lesser known causes include weight gain, development of muscle hypertrophy with exercise, and as a side effect of oral and topical medications particularly steroids.
Up until recently very little could be done. Billions of dollars have been spent on creams and treatments that basically do nothing. Over the past several years though laser technology has made dramatic improvements in their treatment. In the best-case scenario, stretch marks are detected early and some level of redness or inflammation is present. In this case, a pulsed dye vascular laser (V-Beam) can be used to stop their progression. Once the tissue appears stretched, whitish or dark, other technologies must be used, notably fractional non-ablative lasers such as the Fraxel Restore. In general, I am surprisingly impressed by their efficacy. Now, as expected, nothing will remove them completely and several factors such as skin type, severity, and body location will play a strong role in how much improvement can be achieved. What I could say, is that for many patients that are good candidates we can minimize stretch marks by 80+ %. Universally, several relatively simple, low downtime treatments are necessary. Often a combination of technologies mentioned above must be used in conjunction with topical agents. The good news is that we now have pretty solid protocols that will give patients much greater comfort and hope in the improvement of these common scar-like embarrassments.

A large part of my practice is treating patients with old acne scars. Many come in expecting the magic of lasers to erase their woes. Unfortunately, if the acne persists I am often very wary to convince patients into scar treatments. “You cant heal a bruise without first stopping the punch in the arm” is my lingo. It is imperative to stop acne that is scarring. Many of these patients have used every cream and antibiotic under the sun and have entered adulthood with an unrelenting problem. Contrary to the popular belief of Accutane being an evil and dangerous drug, it is still to this date the only possible cure for acne and certainly the only wonder drug in dermatology. Unfortunately, those that put down the drug don’t consider acne a real medical disease which requires real medicine. Like any drug such as anti-hypertensives, anti depressants, cholesterol lowering drugs amongst others, Accutane can and does have controllable side effects. What is different is that with Accutane you DON’T have to take it for the rest of your life like other drugs. For Most people 5 months of Accutane can effectively and dramatically reduce or cure acne for a decade or more. The main concern of the drug is its effect on the babies of pregnant women. The key is not to get pregnant on the drug. It does not affect fertility and most drugs for medical conditions cause birth defects as well. The problem is …is that Accutane is often given to women of child bearing age. As with any medicine it must be prescribed and taken responsibly. The other concern, which I have not seen much of in my 15 years of writing the drug, is the risk of exacerbating or causing depression. If it were the case, again, numerous drugs that are used every day for high blood pressure and anxiety carry the same risks. As with any drug, patients have to be monitored and doses adjusted so patients can tolerate the medicine. Fortunately, after a 5-6 month course of the drug all effects of the medicine resolve except the Acne. It is sad that this drug is becoming less and less available to thousands of patients that suffer from severe acne. I certainly plan to continue treating my more severe patients with this drug that I have had almost universal success with.

Well, summer is here and needless to say the sun is out and people are gonna get burnt.  Most of the sunburns I see in my practice are actually in the early parts of the summer. People are so excited to get outside and get a bit of color ignoring that their skin is winter pale and not prepared for the exposure.  Avoiding appropriate sun protection exacerbates the problem.  Unlike many Dermatologists, I am not totally anti-sun.  I love the beach and look forward to summer as much as anyone. BUT….i do not sundial myself on a chaise trying to evenly bake myself all day long.  Light exposure certainly has health and mood related benefits. I enjoy outdoor activities with sun protection on and generally avoid sitting in direct sunlight during peak sun hours of 11:30 – 230. Sitting in the shade with a book or taking a long lunch is usually a lot more comfortable than sweating in the heat anyway.  The problem is that people do not know how to control and limit their exposure. Certainly there are more high-risk people than others. Certain ethnicities and skin types can certainly tolerate sun exposure better. Anyone with a personal or family history of skin cancer or individuals who spend significant amount of time outdoors should certainly be judicious in protecting themselves as well.  Now unfortunately, most patients who are burnt or just way too dark cry over how they put on 30, 50 60 +  sunscreen and they don’t understand how they got that way. Well, the fact of the matter is most people do not use sunscreen appropriately. Sunscreen should be applied 20-30 min before sun exposure ( not an hr into the beach experience and just before u take your first dip). In addition, no sunscreen is truly water resistant. Always reapply after a significant dip. Use a significant amount. This is not a product to apply stingily. And finally, don’t be fooled that any number spf is goin to protect you all day. Unfortunately, the spf rating between products are not always relative and are generally not as protective as people assume. Be smart and apply any sunscreen every couple hours if your outside all day. In general, I prefer sunblocks with zinc oxide and titanium dioxide. Fortunately, these ingredients now come in more cosmetically elegant formulations that are micronized so it doesn’t feel like rubbing white paste on oneself. So….the general gist of this diatribe is….enjoy yourself, be smart, expose in moderation, use appropriate protection, and take the most precautions with your children and those with significant susceptibility to skin cancer.  Happy Summer!

For the past decade or two, the gold standard for treating deep wrinkles, scars and severe sun damage has been resurfacing with a CO2 laser. This technology replaced deep chemical peels with Phenol and Dermabrasion. Although extremely effective, the original laser technologies were fraught with long recoveries (several weeks) and modest degrees of risk with scarring and altered skin pigmentation.  Although non-ablative technology (non- cutting) has changed the way we resurface the skin, the less invasive technologies still do not have great efficacy on deeper wrinkles and scars, particularly around the mouth and eyes. The Fractional technology I have mentioned before has been recently applied to the old CO2 technology to accommodate these purposes. The two strongest and most effective devices on the market are the Fraxel Repair and the Active/Deep FX. There are many copycat technologies that claim faster healing times and less pain but this is true only because of their lack of power and efficacy compared to the stronger technologies.  Pixel, Affirm, Matrix, eCO2 and many other brands fall into this category. I currently used the Fraxel Repair as i have found that the few devices the company has  to offer provides the full spectrum of treatment options, the greatest amounts of clinical studies and the most powerful technologies.

So…the main goal and advantage of the Fractional CO2 technology is to come close to the efficacy of the old CO2 lasers with significantly greater safety and less downtime.

In my own experience with the Fraxel Repair, I have consistently found recovery to be 1 week at home then an additional week of makeup tricks to cover the remaining redness and mild puffiness. Usually by the end of the second week, only the patient and Dr can appreciate the subtle redness that remains. Patients do need 1 week off from work and 2 -3 weeks before any major social event. I generally tell patients 1-2 weeks for 15 years off the skin….which is exactly the results I have been getting. The procedure is done under local anesthetic and although the look of recovery is tough, it is painless. I do have all the other less invasive Fraxel technologies in my practice but for significant wrinkles or scars, the Fraxel Repair has certainly been the most effective. For the many who cannot afford the downtime, the Fraxel Dual can be performed. Check out pfrankmd.com to read more about the fractional technologies.

So  I discussed in an earlier blog fractionated laser technology. Well, things keep getting better. I also mentioned that I preferred the original name brand that invented the technology- Fraxel. One of the reasons I dig the brand is its continued innovation. There has recently been a spectacular upgrade to their non-ablative (non cutting) technology called the Fraxel Restore. The new version is called the Fraxel Dual. Mostly because they added a second wavelength of light to the device, called the Thulium,  that is specific for superficial sundamage and hyperpigmentation. The laser is still fractionated so the safety is excellent and recovery is remarkably fast. So in the same device both superficial issues such as sun damage and deeper issues such as scars and wrinkles are treated at the same time. Depending on the patient,  the two wavelengths can be used as separate entities or together in one treatment. What I have loved using this newer version for is patients with diffuse brown sun damage. In only one treatment I can now erase 10+ years of pigment with one treatment and only 4 days of a non- painful sunburn like effect. Traditionally, it would either take other devices with a longer recovery or 4-6 photofacials to achieve this result. Thumbs up to Fraxel!