- Chemical Peels
- Keloids and Hypertrophic Scars
- Skin Cancer/Lesion Excisions
- Laceration Repair
- Scar Care
Most fillers used today are hyaluronic acid; this material is injected under the skin and gives volume precisely at the location it is injected. Most of the time, these materials come in 1 ml syringes, so that a patient will receive one, two, or more syringes. To be fair, 1 ml is a small amount of material—a teaspoon is 5 ml—and so the treatment is precise and addresses a very specific area.
Fillers are best used to treat depressed wrinkles, such as the nasolabial folds, or areas that need more fullness, such as the cheekbones or lips. Sometimes it is injected into the tear trough or the prejowl sulcus. In these areas, the material increases the fullness and brings the skin out. It is important to remember that while sometimes an area needs more than one syringe, we also want to put as little as necessary to not overcorrect. A common strategy is to start with one syringe and then add more as needed. I also think it is very helpful to limit treatment to a single area (such as the left and right nasolabial folds), rather than to take a syringe and inject multiple areas in one session. Injecting multiple areas in one session, especially with one syringe, tends to result in multiple areas with minimal improvement which can be frustrating. Finally, I think it is important to remember that the goal is to make the face look holistically better, and that we are not dealing with a series of imperfections that need to all be addressed. The reality is that by making a few changes, the face can look considerably better. One strategy is to select one area that is of higher concern, or perhaps one area that is of concern and is particularly amenable to treatment and address that one area first. Often by improving one or two areas, the face looks good, and it is unnecessary to treat every single area that might have been identified for treatment. Ultimately the goal is to make as little intervention as needed to give a pleasing, natural appearing result.
Following treatment, it is helpful to apply ice for ten to fifteen minutes. The tissue swells and usually takes a few weeks for that to improve. In the lip, swelling can last up to one month, and this is important because the effect of the filler is usually visible in three to four weeks. Sometimes patients see the lips swollen at first and like the results, only to find it fades after a few weeks or month. It is not the filler that is fading, but the swelling, and the result at one month out is effect of filler alone without swelling. Fillers usually last for approximately one year, although some fillers last longer in certain locations on the face. Bruising sometimes occurs, but that usually is minimized with ice. Most patients who get fillers will repeat on an annual basis; in patients who want more volume, sometimes a syringe is placed every six months to keep the volume at a plumper level.
Injectables have revolutionized cosmetic treatments over the past two decades and have given us opportunities to help patients with a diverse array of needs and desires. Injectibles refer to those medications that are injected directly, and can be divided into two broad categories, the neuromodulators (such as Botox and Dysport), and fillers (Restylane, Juvederm, Voluma, and so forth).
Neuromodulators: Botox and Dysport
The neuromodulators work by relaxing muscle, and usually we are treating the upper 1/3 of the face—the glabella (the area between the eyebrows), forehead, and crow’s feet (the wrinkles on the outside of the eyes). There are many other areas on the face and throughout the body that are treated, but I usually try to limit treatment to these three areas which tend to work in a highly effective, reproducible manner.
There are several interesting features about these medications. First, they do not work immediately; they can take from three to seven days to have their effect. The implication is that I do not see the effect while treating, and so there is always some uncertainty about the treatment. I usually inject the same amount of medication on both sides, but if the muscles are slightly stronger on one side, asymmetry can result. Second, these agents are temporary. They last four to six months, and most begin to wear off after about five months, which is why most patients are scheduled for treatment every four to five months. Third, they do not have any known permanent effects, so that if you treat and then stop treating, you simply return to your state you would have been without medication. Finally, the results tend to improve over time. Assuming treatment occurs on a regular basis (every four to five months), each subsequent treatment tends to look better than the past, mainly because the muscles have a slight atrophy that smoothens the tissues. If a patient then stops treatment and the muscles become strong again, and then resumes treatment, the results resort back to that of an initial treatment.
Neuromodulators work by weakening the muscles, so that you will not be able to move the muscles as much. The result is that the skin does not wrinkle as deeply, and the glabella, forehead, and crow’s feet tend to soften. In my experience, the degree of relaxation is between 50-70%, and with time can increase above 90% with subsequent treatments given before the muscles have a chance to regain strength. Many patients have continued treatment for years, and we have not seen any long-term adverse effects, nor any resistance of which I am aware.
The position of the eyebrows can be a source of frustration for many patients, particularly following the first few treatments. The reality is that the forehead muscles raise the eyebrows, and as there is increased laxity with age, these muscles pull harder and create frowns and wrinkles in the forehead—these are the wrinkles that patients are often coming to treat. The neuromodulators work by making the muscles work less powerfully, and this has two effects: (1) the wrinkles will be reduced because the muscles cannot pull as hard, and (2) the eyebrows will drop because the muscles cannot pull as hard. The first effect is loved by patients; the second effect, not so much. The reality is that these two effects are linked by the same mechanism. We would love to have an agent that relaxes the wrinkles but lifts the eyebrows, but it doesn’t exist. There are two strategies to help patients with this dilemma. First, the amount of medication placed in the forehead can be moderated, so that we achieve a mild to moderate improvement in forehead wrinkles, without significantly dropping the eyebrows; by repeating treatment on a regular basis (every four to five months), the muscles will slowly atrophy and smoothen, and wrinkle reduction can be achieved without dropping the eyebrows. Second, in females, less medication can be placed over the outside of the eyebrows. This strategy allows the forehead to continue to pull the sides of the eyebrows up, offsetting any drop in the middle part of the eyebrow. Of course, the degree to which the lateral eyebrow elevates tends to vary based on how strong the forehead muscles are on the sides; some patients have very strong muscles here, and some patients’ muscles are mild on the sides. Of note, there are other strategies to raise the eyebrows (such as injecting antagonist muscles under or on the eyebrows), but I have found these maneuvers to be inconsistent in their results and can be associated with problematic side effects such as eyelid drooping; I find the risks do not warrant the use of these other strategies.
After treatment, there are often small bumps and sometimes bruising that usually resolve promptly. I ask that ice be applied for the first ten minutes on the treatment sites, and at that point no further intervention is needed. There is no need to limit your activity afterwards—no need to limit head position, exercise, or any dietary changes.
On the day of the procedure, wear loose-fitting clothing and minimize any makeup or other materials on your face. If you have a history of cold sores or viral outbreaks, then let the physician know as antiviral medication is often prescribed.
Once the peel is performed, you will wash your face with cold water for five to ten minutes, and then a bland ointment such as Aquaphor is applied. For the first week, repeatedly apply Aquaphor or Vaseline or some other bland ointment to keep the skin greasy. When out in the sun, be diligent with sunblock for at least the first three months as the skin will remain sensitive to sunlight. It is also helpful to eat a low-sodium diet to minimize swelling. Most patients find that they can return to their normal routine after one week.
Chemical peels have been used for decades to improve the appearance of the skin of the face and the neck and are some of the oldest cosmetic techniques in modern use. The principle of the skin peel is to remove some of the outer layers of the skin, allowing new skin to regrow that is softer and smoother. In addition, the peel tends to heat the deeper skin layers, creating a tightening and new collagen formation.
Peels can vary in their depth and strength; many of the lighter or blended peels are available at spas; the peels that I perform are deeper peels. My agent of choice is trichloroacetic acid (TCA), as this is one of the oldest and most robust peels in practice.
TCA peels vary in strength from 10% to 35%, with the 35% TCA peel being one of the strongest peels available. One peel—the phenol peel—is stronger, but I do not perform it as can have some significant medical and cosmetic complications. Aside from the phenol peel, the 35% TCA peel is one of the strongest peels available and its safety and reproducibility make it quite attractive.
The TCA peel can be used at 35% or diluted to lower concentrations. Depending on your skin type, the concentration is varied to achieve an effective result with minimal risk. Patients who have pigment (such as melasma) are at risk of it worsening with a peel, so those patients usually either avoid peels or have them at lower concentrations. The peel process itself is simple: I usually treat the neck and full face in a session, first by degreasing the skin and then by applying the TCA liquid for two to five minutes. It is then washed off with water, and then a moisturizing agent is applied. The skin becomes quite red and starts peeling within several days. The redness can last from one to several weeks, and the results usually become apparent in one week with improvement visible for several months. There are some patients who only have a mild effect with a peel; in those circumstances, a second peel several weeks later can have a much-improved effect. Once the patient finds that a TCA peel is effective, they can repeat it on a regular basis every one to two years.
While most wounds heal with a soft, flat scar, sometimes the skin heals with thickened, raised scars that are known as keloids or hypertrophic scars. Keloids and hypertrophic scars are separate entities, but they share many common characteristics and are often treated in similar fashion. There are four main features of keloids and hypertrophic scars: the scars are firm, elevated off the surface, of a darker hue, and sometimes they itch. They tend to run in families and people can be predisposed to them.
I have a particular interest in keloids and hypertrophic scars and treat a large number in my practice. The key to their treatment is to understand that if they are simply cut and re-sutured, they tend to recur more aggressively. Treatment should be tailored to changing their biology first, and then if they need to be removed, they are removed only after they have improved.
The most common first-line treatment for keloids and hypertrophic scars is triamcinolone (Kenalog) a weak steroid that is injected directly into the scar. Triamcinolone does four things: it softens the scar, lowers it, lightens the hue, and makes it itch less. It is a weak medicine, and often takes three to four weeks to work. It is usually injected in small doses one month apart, and many patients need a series of treatments to achieve the desired result. After the triamcinolone treatments, if the keloid or hypertrophic scar is still disfiguring, it can be removed, and when it is excised following triamcinolone treatment, the risk of recurrence is much lower.
There are some patients for whom triamcinolone injection does not work, and in those instances other treatments are available. Before discussing other treatments, let me add that I sometimes see patients who have failed previous triamcinolone treatment elsewhere, but then I will try it and it works. What I find is that in some patients they need a longer series of treatments before the effects are visible, and given the safety and effectiveness of intralesional triamcinolone, I prefer to optimize its use before moving on to other treatments.
In addition to triamcinolone, there are other treatments that have been used on keloids and hypertrophic scars, including silicone gel and sheeting, pressure therapy, 5-fluorouracil, and several others. Some of these modalities are quite effective. For example, in earlobe keloids, I will often use multiple triamcinolone injections, excise the keloid if it is large, and then use pressure earrings that are lined with silicone sheets. Particularly for more challenging keloids and hypertrophic scars, multimodality treatment (using multiple strategies) is particularly effective; in more straightforward situations, triamcinolone by itself, injected multiple times, works quite well.
Many people have suspicious skin lesions or masses just under the skin that need to be removed and biopsied. When these lesions are removed, they are often sent to a laboratory that examines the tissue under a microscope; a formal report is generated about two weeks later those states the nature of the tissue and whether it contains any concerning cells.
Some lesions are sampled with a shave biopsy. In a shave biopsy, a sharp blade passes through a few layers of the skin to sample the tissue, and the wound is superficial and heals by itself. A bland ointment such as Vaseline or Aquaphor can be placed on the wound until it heals, and a bandaid can be applied if desired. The wounds can be washed the day after the procedure with soap and water.
Most lesions are excised “full thickness” where the entire lesion is removed, including all the layers of the skin and some of the underlying fatty layer; these wounds are then sutured in layers. The deeper layers are closed with absorbable sutures that last about one to two months; the superficial layer is closed with absorbable or non-absorbable sutures. Non-absorbable sutures are used in areas of cosmetic concern as the resulting scar is superior; these sutures need to be removed anywhere from one to two weeks depending on the location. These areas can be washed the day after the procedure with soap and water, and it is not uncommon for some fluid to egress from these wounds for the first one to two days. In some instances, a steristrip is applied (white tape); these should stay on as long as possible and usually remain for one to two weeks. In other instances, a bandaid or gauze is applied at the time of the procedure; this covering can be removed, and antibiotic ointment can be applied once to twice a day for three days (do not use antibiotic ointment for more than three days). These wounds can all be washed with soap and water they day after the procedure; do not use any caustic material (such as alcohol or hydrogen peroxide) on them. Sutures are removed by the physician one to two weeks later. After suture removal, cocoa butter or shea butter applied daily for one to two months provides the optimal scar appearance. In addition to these agents, please apply sunblock liberally for at least three months following the procedure whenever exposed to sun.
Lacerations and injuries can be traumatizing, and fortunately plastic surgeons have many tools available to give patients the best possible outcomes. Often patients come to us directly or we get called from the emergency department for a laceration and become involved in its treatment and management. Realistically, these wounds should be closed within one to two days, but sometimes they are not repaired for several days or a week, and even in those settings excellent results can be achieved.
Most lacerations result from a direct insult to the skin, either sharp or blunt, and the quality of the skin at the edges is sometimes compromised. When we repair these lacerations, we will sometimes use magnification to look at the quality of the skin at the edges, and any jagged or compromised skin can be sharply trimmed to get higher-quality skin at the edges of the wound. The skin is then usually repaired in two or more layers, using an absorbable suture in the deeper tissue that reduces tension at the surface, and then a second, fine usually non-absorbable suture on the surface. The wound is usually covered with a steristrip tape or antibiotic ointment, and the outer sutures are removed in one to two weeks.
After the sutures are removed, scar care is important to get the best possible result. There are two main components to good scar care. First, scars tend to be sensitive to sun exposure for the first few months, so diligent sunblock (SPF 30 or better) needs to be applied to the area of the scar two to three times a day (if swimming, it needs to be reapplied every hour while in the water). Second, there are several scar medications, including Mederma, Silagen, ScarGuard, that are sold commercially, as well as generic agents such as cocoa butter, shea butter, and vitamin E. I have found that the combination of cocoa butter and aggressive sunblock use can be highly effective and encourage its use for six months. The result of a scar is usually achieved in six to twelve months.
Sometimes scars heal in a less than ideal fashion, and scar revisions can be performed. There are three main strategies that can be used. First, the scar itself can be excised and repaired again. The main advantage is that the new wound is created with minimal trauma to the skin edges that then would result in the optimal scar. A second strategy is that the scar can be dermabraded—scraping the superficial layers of the skin at the scar site—which often leads to a smoother resurfaced appearance. Finally, some scars can be improved with laser treatment. While I do not perform laser treatments myself, I would refer you to an appropriate physician.
Most scars evolve through a process of wound healing where the body builds tissue to achieve wound closure, followed by a maturation phase where the growth slows down and the scar softens. Many agents are available to help with this process and achieve the best scar possible.
There are two components to scar care. The first component is sunblock since the fresh scar is particularly sensitive to the damaging effects of sunlight. Physical obstacles such as a hat are remarkably effective but can be difficult on a consistent basis. Sunblock creams work well, should be SPF 30 or better, and need to be reapplied regularly. My recommendation is to apply sunblock on a scar every morning for the first six months, and then reapply throughout the day as needed. Many patients will keep a small sunblock tube in the car or bag or at work and reapply three to four times per day. On particularly challenging area is while swimming, as many sunblock agents wash off within an hour; hourly application is recommended if possible, and additional use of a hat or other physical barrier will help.
The second component to scar care is a scar gel. Multiple agents have been used, including silicone gel, onion skin extract, vitamin E, and cocoa or shea butter. Several commercial agents are available and are extremely effective. I do find that cocoa butter or shea butter tend to work quite well, and combined with sunblock, can result in a superb scar. These agents need to be rubbed on the scar, beginning after sutures are removed. Interestingly, the process of rubbing the agent on the scar might be critical to their effectiveness. Many of the commercial agents (Mederma, Silagen, Scar Guard, and so forth) contain sunblock in them, making them a single-use agent. I do recommend continuing use of these materials for at least six months, and up to a year if possible. If after one year the resultant scar is not acceptable, return to see your plastic surgeon for other options, as there are several modalities that might result in further improvement.