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.

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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!

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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.

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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!

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The eyes have it!!!!

As the most commonly complained about area on the entire face, there are so many aspects to ageing around the eyes both in cause and treatment. Patients so often complain of the “tired look”. Because of numerous treatments available, I thought I would address this essential cosmetic unit of the face in my blog. First off, sun causes many of the problems in this area. The skin is generally thinner and more sensitive than any area of the face and thus very susceptible to radiation damage from the sun in the form of hyperpigmentation and fine lines. Also, there is a strong  genetic factor in ‘circles around the eye” . Many teenagers even suffer with purple rings around the eyes that sleep does not resolve.  Although it is not completely clear, it appears that this discoloration is similar to a bruise from leaky blood vessels around the eyes. In addition, as we age, the soft tissue or fat redistributes. Some get bags, some get hollow rings, some both. All of these things contribute to the changes in skin looseness and wrinkles.  So with all these factors …what fixes it all? Fortunately, a combination of several small things make a huge difference without having to do major surgery in those with mild to moderate problems..Unfortunately, those that have let the problem get severe over the years have limited options other than surgery.

To start, using a good eye cream with antioxidants, bleaching agents and sunscreen will certainly help. Retin-A like compounds, if tolerated, may help if used over the very long term, as well. Using fillers around the eyes, either Juvederm or Restylane can help reorganize the soft tissue so the hollows are filled and the appearance of  bags are reduced. This is truly a great treatment that people love in this area. Although very effective, it must be performed by someone who really knows what they are doing with fillers as it can easily not look right.  And lastly, there are several lasers and radiofrequency devices that can significantly tighten skin and treat fine lines around the eyes. Although is has a bit of downtime (5 days of bad sunburn like effect) , the Fraxel Repair , fractionated CO2 laser does wonders to tighten skin and smooth out wrinkles in only one treatment in this area.

So there you have it….there is hope for the eyes. Technology has come along way in this realm.  Do your research, see someone who has a lot of experience in this area, and remember it is easier to clean up a room when it is not too dirty. So do something about it when it starts to bother you not when it is really bad.

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Ah yes, another filler battle ensues…… People want to know “which is better”. The short answer , to me, is Radiesse. Many well respected dermatologists and plastic surgeons would disagree. Which is fine….this is my blog …they can start their own. The long answer goes like this.  Radiesse and Sculptra are both FDA approved fillers that work best for overall volume enhancements….cheeks , chins, temples, hands, etc.  Both put “air back in the balloon”, so to speak. Both can be used to achieve excellent cosmetic results that depend more on the injector than the substance itself. So aren’t they just interchangeable?…..not so much.   I like Radiesse for several reasons. First, it is a natural substance already found in the body. To date I have seen zero reactions. Sculptra is made of a substance that is foreign and more reactive (many sutures are made of similar material).  I have seen many reactions or unsavory aesthetic results pass through my office, fortunately from other injectors. Sculptra does last longer than Radiesse but I have found it much less predictable – meaning in some patients it disappears too quickly  and doesn’t cause enough of an clinical effect or the filler develops too much and lasts way to long. Much of this lies in the fact that Sculptra must be performed in several treatment sessions with the effect “building’ over time. Radiesse, I inject whatever I need in one treatment session and the results are in general, immediate and predictable.  And finally, Radiesse, I have found, to be much more cost effective for the patients and the physician. In my practice, 1 1.5 cc syringe of Radiesse has been equivalent to one bottle of Sculptra in patient effect. The substance itself is cheaper than Sculptra and the ability to perform all  necessary filling in one treatment session allow the physician to discount the additional syringes used. So there you have it. Being the only juror in this discussion, I am certainly biased. My opinion may change but Radiesse works for me and my patients. Obviously they both exist because there are many that like Sculptra. Only time will tell if one is superior.

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With so many lasers on the market, patients get very confused on what is what, particularly when it comes to fractional laser technology. Fractional lasers are devices that deliver laser energy in a novel way that has changed the landscape of laser surgery forever. The technology has been around about 4-5 years with advances developing every couple years. Fractional resurfacing offers an improved balance between safety, efficacy and recovery time by treating skin in a ‘pixelated’ fashion.  Although the entire skin surface visually appears treated, microscopically there are treated areas separated by untreated areas. In effect, the healing tends to be quicker and safer. These areas of treatment are called microthermal zones, and they have changed the way we treat the skin.; allowing us to deliver laser energy to greater depths into the skin without increasing risks. Now the name Fraxel is actually a name brand of a laser developed by a company called Reliant that innovated the technology (now it is Solta medical).  Since its release about 5 years ago there are numerous copy cat technologies out on the market – pixel, active FX, matrix, Pearl. Deka, accent and so on. The differences between them all go beyond this discussion but the long and short of it is that I prefer and own the Fraxel brand of technologies. They are, in my opinion, the Rolls Royce of such technologies with the greatest clinical research and certainly the most progressive innovations. They have three different fractional technologies, providing a huge array of clinical applications and a broad spectrum of options for patients who have different needs in regard to results , recovery and risk. I will in, future blogs,  address each of these technologies which represent significant part of my laser practice. Now I am not saying that the Fraxel namebrand is the only effective technology. As with most technologies, the clinical results depends mostly on how the device is used, meaning the skill of the doctor to select the appropriate patient and then use the device to provide an expected result.

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So….i am not sure how i felt about Dysport a few months ago when i first posted about it ( i dont remember what i did yesterday for that matter). I do have a decent impression of it after 6 months of very regular use and patient follow up. And the verdict is good. First off, it definetely kicks in quicker that Botox (my own face kicked in, in only 1 day). As for the length of effect- i have found, with the right dose, i can get it to last about as long as Botox, in the right patient. In older patients or those with deeper wrinkles, maybe its length of action is about 10 percent less in time. BUT…which is a surprising plus….i have definetely found that in the many patients that have used Botox for years and are getting decreasing aesthetic returns in both length and quality of wrinkle reduction, Dysport has given this group a new ‘boost’. I compare it very much to a chronic wine drinker who no longer gets that tipsy buzz they used to get. Give that person a gin and tonic and they are on the floor dancin!. I do believe there will be a role in the future to maybe alternate Botox and Dysport in the same patient. Also….on younger patients and 1st timers Dysport has been equally effective. Thus far it represents about 20-25% of my ‘toxin injections’. Botox still is the #1 name brand and for patients that have always done well with it, i see no reason to change. It is nice to have options…no one likes a monopoly. I do believe Dysport will also play a strong role in the treatment of excess sweating. Stay tuned.

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Every once in a while there is a headline in a newspaper or beauty magazines describing the hideous scarring that was induced upon an unknowing soul as they received a laser or similar procedure meant to enhance their beauty. In my office, I see these patients several times a week. Fortunately, for me, these were not traumas induced by my own hands. Almost always there is a story that involves a “medical spa” or “ Laser Clinic” or sometimes even worse……a hotel room or the back of a nail salon where someone was performing ‘beauty injections.” Although complications can occur with relatively safe cosmetic procedures performed by highly trained cosmetic physicians, the overwhelming majority of stories involve individuals who are not physicians performing the procedure. A laser is a fancy knife and minimally invasive procedures such as injectables are still technically invasive. An individual wouldn’t allow a non physician to perform surgery with a knife on them …so why do they allow aestheticians, “laser technicians’ , nurses , PA, or individuals with no medical training whatsoever to perform cosmetic treatments on them. I am still trying to figure this one out. As a physician, I am only as good as the experience I have performing a procedure. But most importantly the skill of a doctor shines through not when all is well…but how we perform during the hopefully infrequent occurrence of a complication. Unfortunately, individuals without medical degrees do not have the experience, the prescription pad, or the general tools used to handle complications such as burns, allergic reactions, infections and so on. Yet in many states, such as New York , loopholes exist that allow non physicians to perform several cosmetic procedures including lasers and injectables. When a problem exists patients are left out in the cold. Now sometimes these procedures are performed in a doctors office and sometimes not. Most of the time there is no doctor supervision and therefore quality control is lost. Now I am sure there are nurses and PA and pediatricians and internists who may give a good Botox shot and perform laser hair removal quite well, but if a patient has a unwanted reaction or a burn or a displeasing cosmetic result can they handle the medical , emotional , and legal ramifications of the that reaction…….my opinion is –usually not. Unfortunately, 5-10 percent of my practice is handling complications, most commonly of non physicians in spas or non core specialty doctors trying to “get into the cosmetic game’. In most states, including New Jersey, any individual that uses a laser that is not an MD can be arrested for impersonating a physician. There are no Laser Spas. As u can imagine, the horror stories are therefore fewer and farther between. What will decrease the number of sad stories? Either legislation that delegates specific training requirements of those performing procedures or public awareness of the stories that make patients steer clear of those non properly licensed.

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What is Selphyl and is it a new anti ageing breakthrough?. Selphyl is a name brand of a treatment protocol for harvesting and injecting “platelet rich plasma”. This is a biologic substance derived from one’s own blood. Used successfully in orthopedic procedures for years ,“PRP’ treatments has helped promote healing by utilizing growth factors from harvested blood.
For cosmetic use, The procedure takes about 20 minutes to draw and process the blood of a patient. The substance is then injected in to wrinkles and scars to achieve a filling effect. The question is – does it work and how will growth factors improve wrinkles and scars which aren’t really a type of wound. Pros- this is a natural substance from one’s own body and it will have some sort of a filling effect Cons- it will unlikely have the same filling or lasting effect of many of the fillers on the market currently and it is unlikely that growth factors are going to dramatically change wrinkles and sundamage.
This may be a good option for those who cannot tolerate other fillers or as a adjunct to other procedures. The goal is that injecting one’s own growth factors may help to rejuvenate the skin over time. We shall see!

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