What About C?

The penetrating sun’s rays and exposure to various environmental assaults produce free-radicals that cause damage to the epidermis, break down collagen, and produces irregular pigmentation. This is commonly termed photoaging. The result is skin with fine lines and wrinkles, sallow color, rough surface, and irregular brown spots and pigmentation. Antioxidants counter the deleterious effects of these free-radicals. We naturally produce antioxidants, but not enough as we age. The addition of nutritional supplements has gained popularity. Whereas these supplements added to diet may be beneficial for a whole host of conditions, antioxidants for the skin are most effective when applied topically. Through their direct effect against free-radicals, antioxidants prevent premature signs of aging and protect against future damage. By stimulating collagen production they improve the skin’s structure to help restore tone and function. And by suppressing melanocyte activity they decrease irregular pigmentation.

Vitamins A, C and E, along with beta-carotene are the most common topical antioxidants. Vitamin C is perhaps the most effective. Various vitamin C preparations are available. It is important to use one that has deep penetration, is stable, is fast acting with quick absorption, and is of professional strength. Topical anti-oxidants are an integral part of an effective skin care regimen.

Hydroquinone Safety

There has been some rumbling about the safety of hydroquinone in a skin care program. Evidence cited of the questions surrounding hydroquinone is that it is banned in Europe and that the FDA is reviewing its safety. These statements are not exactly true.

Let’s review: Hydroquinone(HQ) is a chemical that is used topically to reduce pigment formation by pigment-producing cells deep in skin. It is prescribed to treat unwanted and irregular pigmentation. HQ concentrations of 4% and greater are sold by prescription only, and lesser concentrations used in over-the-counter (OTC) preparations. Prescription-strength HQ has been a component of the Obagi® NuDerm system for years, and most recently, part of the Obagi® Décolleté system. I have personally used and prescribed this system for over ten years.

Hydroquinone has been widely and safely used as a skin lightening agent in the United States for 30 to 40 years, and nothing has been found to be as effective as prescription-strength HQ. In Europe, HQ has been banned only as an OTC preparation on fears of possible link to cancer, but is still used by prescription. In 2006, the FDA began a review of HQ and a possible banning of the OTC use was discussed. The reason cited for the proposed ban is that some studies in rats suggested that hydroquinone may cause cancer, which has yet to be proved in humans. As of today, the FDA has not found evidence to limit OTC hydroquinone.

According to Ellen Meyer Schneider, Contributing Editor Skin & Aging:
“The data on rats and mice cited by the FDA cannot necessarily be extrapolated to human data,” she asserts. What’s more, she says, a link to cancer is not apparent in the very population that has experienced ochronosis. “We have not seen a proliferation of various types of cancer from the African population, even among those who have used hydroquinone for 10, 20 or even 30 years and in high concentrations. Nor are there any data supporting human cancers in workers who are exposed to high levels of hydroquinone in film or lithography processing.”
http://www.skinandaging.com/article/6562

A recent review by Nordlund sums-up the current status:
“Hydroquinone is one of the most effective molecules for the treatment of hyperpigmentary disorders, with over 40 years of efficacy and safety data.” He concludes: “However, despite 40–50 years use of hydroquinone for medical conditions, there has not been a single documented case of either a cutaneous or internal malignancy associated with this drug. This article reviews the evidence for the safety of hydroquinone in the treatment of hyperpigmentation conditions.”
The Safety of Hydroquinone. JJ Nordlund, PE Grimes, JP Ortonne. Journal of the European Academy of Dermatology and Venereology Volume 20 Issue 7, Pages 781 – 787, 2006

Like many medications such as topical antibiotics and steroid creams, hydroquinone has been proven effective. There are potential side-effects and opportunities for misuse, so it is available under the guidance of a physician as part of a medically designed skin care program and available by prescription world-wide.

The Eyes Have It

Recently, I saw an article in a popular fashion magazine regarding “non-surgical” treatments for improving the appearance of people’s eyes. Remedies included tea bags, cucumber slices, eye creams and camouflage make-up techniques. Generally, the concerns my patients have regarding their eye areas include wrinkles, loose skin, dark circles and excess fat. The causes of these concerns are often the result of gravity and aging, and, less commonly, visible veins or dark pigmentation. The “non-surgical” treatments promise great results, but may fall short on delivery. Many times only more invasive procedures will solve the underlying issues.

Fine lines and wrinkles result from collagen breakdown in the skin. Moisturizing with topical eye creams will “soften” the appearance, but most eye creams make no structural improvement. Certain lasers, chemical peels and prescription topical medication will improve the collagen and elastic fibers. Additionally, these treatments can remove sun damaged skin and reduce excess pigmentation for a real transformation.

In some cases, an injection of filler material, such as Restylane, under the skin in the tear trough or around the orbital rim may provide a temporary solution to under eye bags or dark circles. Also, Botox injected in various muscles around the eyes may smooth out crow’s feet and may even give a lift to the eyebrows.

A small amount of excess skin may be tightened by lasers or chemical peels, but, at a point, only direct surgical excision of the excess skin will change one’s appearance satisfactorily. For bulging fat above or below the eyes, surgical removal or re-positioning is the most effective treatment. Droopiness of the eyebrows and forehead can weigh down the upper lids and create hooding of the eyelids. This condition requires a browlift, a procedure I most commonly do endoscopically. All of these surgical procedures are performed on an outpatient basis. A patient’s “downtime” and discomfort level vary, but are generally minimal.

Deflated and Ruptured Breast Implants

This is apparently the week to worry about deflated and ruptured breast implants. I have received calls this week from a frantic patient worried that her deflated saline implant needed to come out immediately and another patient was worried that her ruptured silicone gel implant was dangerous and was going to spread throughout her body.

Deflated saline implants occur in approximately 3% of the implants in 7 years. A deflated saline implant is obvious - the breast becomes much smaller. When a saline implant deflates, the saline is simply absorbed. Since the saline is the same as IV saline, there is absolutely no danger. The surrounding scar capsule will slowly get smaller, so the implant should be replaced sooner than later to make replacement simpler - but it is not an emergency.

Although older (>15 years old) silicone gel implants approached 100% rupture rates, the modern silicone gel implants have rupture rates much lower than saline implants. A ruptured silicone implant is not so obvious - it is usually diagnosed based on a routine mammogram or ultrasound. When a silicone gel implant ruptures, the gel is contained by the surrounding scar capsule, so it goes nowhere. In addition, the silicone is harmless. The past worries about health risks are unfounded. Again, it is not an emergency.

In both cases, the patients were re-assured about the safety of their situation and replacement was recommended as soon as it was convenient.

Liposuction Alternatives

There have been several news articles recently about different kinds of liposuction and even alternatives to liposuction. Ads for the latest technologies appear in magazines, newspapers, and on billboards - so I get plenty of questions.

Unfortunately, most of the newer liposuction options promise the world - fast, pain free, no risk, no down-time, inexpensive, long-lasting, etc. - but deliver nothing. The laser liposuction technique uses a laser and suction to remove relatively modest amounts of fat - yes, fat is usually removed, despite the ads - with results that are very unimpressive. The claims of no down-time, little bruising, and no anesthesia are the result of the limited fat removal and there is no improvement compared to "traditional" liposuction. In fact, if you consider that you may need to repeat the procedure several times, it will cost more with really no real improvement in outcome!

The various fat-dissolving injection therapies are even scarier. See if your provider can tell you what is actually injected into your body and that the substance injected is safe and FDA-approved. You'll find that they can't.

No fancy machine or injection can make a good doctor. I believe that technology may be helpful in achieving a good result, but ultimately, the result will depend upon the experience of the doctor to do what works best in his/her experience.

Is Outpatient Surgery Safe?

There has been a tragic incident recently where a young woman died after some episode during elective plastic surgery in an outpatient facility. Now, I do not have any information regarding the details of this case, but I do want to comment on outpatient surgery. Specifically, the safety of outpatient surgery. After over 20 years of practice, I have done surgery in hospital operating suites, hospital outpatient surgery facilities, free-standing outpatient surgery facilities, and office-based outpatient surgery. I have done procedures with local anesthesia, local anesthesia with sedation - or "twilight" anesthesia, and general anesthesia. I have done procedures with patients as inpatients - recovering in the hospital for one or more days, and as outpatients - going home to recover after surgery. After all these years, all of the plastic surgery procedures I do are done on an outpatient basis - most with general anesthesia. The facility I use is inspected and certified by the same agency that inspects and certifies hospitals. That means the building, procedures, equipment, and employees all meet strict standards - just like the hospital. Furthermore, the anesthesia is done and my patients are monitored by Board-certified anesthesiologists. The nurses and doctors are all trained in Advanced Cardiac Life Support. With general anesthesia, my patients are guaranteed to be asleep and feel nothing - AND their airway is safely protected while they breathe. I can concentrate on their procedure while they are safely being taken care of by the anesthesiologist. Current anesthesia medications allow my patients to awaken rapidly after surgery and to recover at home. Patient safety is extremely important to me, and procedures done at a certified facility under general anesthesia with Board-certified surgeons and anesthesiologists with a staff trained in ACLS provide that safety.

Am I Too Young?

A 48 year-old woman recently asked me if she was too young for a facelift. She had the usual changes of loose cheek skin, jowls, and prominent muscle bands on her neck. Her health was perfect. What she really wanted to know was it worth doing her surgery now or should she wait until she was older. My response was that improving your appearance now allows you to enjoy the next ten years comfortable with yourself. You may need a touch-up in 5-10 years to maintain the improvement. If you wait, you may not be happy at all until you do your surgery when you are older. My goal is to be sure you are medically healthy for surgery and that what you want will actually make an improvement - at whatever age you choose.