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The 4 Layers of the Aging Face – Part 1

Jun 9th, 2010 by Dr. Douglas Key

Aging can be like a mask that begins to hide who we really are. While aging does not literally create a mask, there really are factors that contribute to facial aging, layering on an older appearance. The good news is that we can now – without surgery – regenerate each of those layers, and truly not just hold even with aging, but regain the health and vitality of your skin and appearance.

I want to talk about the 4 layers of facial aging, and this week I’m going to start with one that we all have very little control over.

The First Layer: Gravity

Gravity is constantly pulling us down, and it’s the skin’s collagen that does the heavy lifting of keeping us looking youthful. But over time, that collagen begins to diminish – and that means it’s time for a skin treatment to gain back the tightness.

Our best approach today is maybe the newest of treatments: Ultherapy. Ultherapy is noninvasive pixels of focused ultrasound energy targeted to tighten the SMAS layer of collagen called fascia that is below skin and fat but above muscle. This is actually tightened in all face lifting surgery. By using Layered Light for Tightening and Lifting, Ultherapy targeted ultrasound can be combined to enhance your improvement with Thermage, Accent or Laser Lifting as well.

Your best results following Ultherapy will be gained over several months. As to how long improvements last, that is always hard to say, but I can say that many of our patients that we treated just with Thermage alone, let alone Ultherapy, still look better today than their pretreatment photos of 5 to 6 years ago, and that’s just about as good as any surgery can do.

Tune in next week to learn about the next layer of the aging face – volume loss.

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The Benefits of Cosmetic Laser Medicine

Jun 2nd, 2010 by Dr. Key

Each day I hear thing like this from patients:

  • “I had my eyes done a few years ago, Dr. Key.”
  • “Just four or five years ago, I had a facelift.”

These patients that I am meeting for the first time will often add, “Things looked good in the beginning but now they are, well, fading way. The results are hard to see today.”

How can this be, patient after patient? The answer is simply that the results from surgery can’t last forever. Most of the time, results are maintained 4 to 5 years.

So what do patients want? Why are they coming to me, a dermatologist in Portland who specializes in laser medicine, particularly if over half of them have already had cosmetic surgery, and the other half has never wanted to go so far as choosing surgery?

The reality is that laser medicine is not just an alternative to plastic surgery, it is really quite a different choice. Laser medicine today offers – and I truly mean this – the choice to heal aging. How can laser medicine heal aging? Lasers, as they interact with the skin, are raising the biology of that skin to a higher level of well-being, a higher level of healthiness. The reason your skin looks a lot better, the reason your skin is tighter, the reason you no longer look “tired” or as old and have a lot more energy shining through, is that laser treatments (not from the local spa or the drop-in-at-the-mall) are effective at reversing signs of aging.

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How to Slim Down and Tone Up

May 28th, 2010 by Dr. Key

A lot of people want to tone and tighten up, maybe losing an extra half inch in their arms, thighs and hips. One of the main problems toning up is the leftover loose skin. There really is no, and I will repeat, no exercise or workout routine that makes skin tighter. And up until recently, the only good option was surgery to remove this loose skin. But now there’s a non-surgical answer.

I have worked with Thermage as far back as being one of their initial investigators, in the early FDA trials before its release for facial skin tightening in 2003, and this treatment has really come a long way. Thermage promotes skin tightening through the effects of radiofrequency microwave energy and collagen rebuilding and tightening. Thermage released a “shallow” energy tip several years after considerable safety evaluation for use around the eyes (the upper and lower eyelids) for skin tightening.

The moderate depth energy tip has been in use for even longer, but improving both in effectiveness and comfort, for noninvasive skin tightening of the face and neck. The deeper tip has evolved from the early trials several years ago, to the newer release of the Thermage NXT treatment tip and platform, with improved cooling and energy profile, as well as improved patient comfort.

Advanced Skin Tightening

Now for the first time we can offer our patients a treatment for tighter tummies, thighs and hips. On the patient trials that we began early in 2009, we’ve tracked results and I would say that a majority of patients are seeing better definition and improved tightening. We can see the results in their before and after photos. This is pretty good for a noninvasive treatment.

For maximum effectiveness in our body treatments, we’ve added a pretreatment with SmoothShapes to target cellulite. The energy of Thermage treatment is matched to each patient. With each patient being different, heavy sedation is simply not encouraged. Instead we are using either ibuprofen or an injection similar to ibuprofen, Toradol. Full activity can be resumed immediately after treatment. Although you can see collagen smoothing and skin tightening results from the beginning, your best results may still be 6 to 9 months away.

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Move Over Facelifts, Move In Ultrasound

May 25th, 2010 by Dr. Douglas Key

What’s moving in? The newest advance in non-invasive tightening. What’s moving out? Surgery.

At this year’s American Society of Laser Surgery and Medicine meeting, the big news was Ultherapy™ for skin tightening and lifting. Ultherapy is micro-focused ultrasound, the same safe ultrasound used to image babies or varicose veins, but the difference is that this ultrasound is focused. Imagine two microscopically small headlights aimed at each other. When the two paths cross, energy is produced. This is where tightening occurs. Now, imagine hundreds of invisible-to-the-eye micro-focused droplets of energy below the skin surface. The energy tightens skin, without the need to cut it. Now you have Ultherapy.

But that’s just the beginning. Ultherapy opens up new possibilities because energy can be focused shallower or deeper and the energy settings can be adjusted (for example, adjusted for the thinner skin above the brows to restore a natural-looking arch or adjusted to lift and tighten the skin under the chin or on the neck, cheek and jowl). That alone is pretty exciting. But there’s more! With Ultherapy treatments in Portland, we are able for the first time to actually tighten the underlying collagen of the SMAS layer. In the past, this collagen layer could only be addressed with a surgical facelift for Portland, Oregon patients.

Let’s talk about treatment. What can you expect? First, we need to develop a treatment plan. Do we want to use Ultherapy alone? Or would it be more effective to combine Ultherapy with other treatment possibilities? For example, today I talked about using lasers to dissolve fat under the chin (laser lipolysis and microlipoaspiration) and combining the laser treatment with Ultherapy for the temples, forehead, cheeks, jowls and chin/neck to tighten skin and shape the neck. It’s a matter of combining art and science together for amazing, lifted results.

At my practice, we have a very clear philosophy: we need to make the treatment fit you, not the other way around.

Ultherapy is a relatively comfortable procedure. We work with our patients on a “1 to 10″ grading scale, keeping discomfort between a “2″ (”I could do this all day long”) and a “3″ (”That’s a bit warm”). We use oral ibuprofen, injectable ibuprofen (called Toradol), or propoxyphene (Darvon), as well as a numbing cream before treatment. Treatments focus on lines of invisible microdots of energy that flow into the skin from the ultrasound transducer, which is applied gently to your skin through cool ultrasound gel.

During the Ultherapy procedure, we’ll treat half of your face, then stop and take a look. The immediate visible change is impressive to everyone – you included – and will continue to improve month-by-month, building over 4 to 6 months. There may be some limited swelling after treatment, but you can still expect to return to work the next day. Although uncommon, bruising can occur but will disappear over the course of a week. Some patients have experienced some soreness, but this will also disappear gradually over several weeks.

The images of improvement with Ultherapy, as shown in presentation after presentation, were impressive with even just a single treatment session, but even more so with a second treatment 4 months later. So think of how much collagen-building and skin-smoothing improvement can be achieved through 1, 2, or even 3 treatment sessions!

I’m not saying that Ultherapy means Thermage®, Accent™ XL or YAG lasers are “out.” What I am trying to say is that we can now add to those treatments, for even better improvement.

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What Men Want

May 13th, 2010 by Dr. Key

“What Men Want….May Not Be What You Think” The new edge of handsome in men has very little to do with lines and wrinkles – BOTOX just isn’t as big a player for men as it is for women. So what do guys want? I believe that cosmetic medicine providers have missed the answer to this question by a mile.

Answering this question requires that we remember that “Women are from Venus and Men are from Mars” – or as was said to me recently “Women are from Paris and Men are from Jersey.”  Men are not too worried about growing older – but they don’t want to be perceived as looking old. After all there are many men in their 40s and 50s who look “distinguished” with gray hair and a few facial wrinkles. Men don’t want to be left out of that group of guys with an “I can get it done, don’t count me out” look.

So let’s talk about where it counts for men and we will make a list that can really make a difference.

  • Highest on the list for guys is that jowl and the area under the chin. Laser lipolysis on a Friday will have you back to work on Monday.
  • Next is probably those eyes, the droopy upper lids and most important those deep under the eye shadows, so forget surgery, what about the skilled physician administered use of Restylane micro injection to lift out those shadows, a maybe as well some of those deeper fold lines. Oh, and what about a series of Thermage treatments to tighten up those upper lids as well.

There are plenty of other cosmetic treatments men are into. Guys – now’s your chance – tell me what’s on your mind and what you’re thinking of having to look your best.

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Reader Question: Wrinkle Relief

May 5th, 2010 by Dr. Key

“What can you do about the lines on my lips, not to mention the lines around my eyes? Oh, by the way, I would like to tighten the skin under my chin, as well. These things bother me the most, Dr. Key.”

Thanks for the question. First of all, there is simply no surgery of any kind that changes these lines, so let’s put surgery completely aside. So what are the choices? The choices range from “not so good” to “truly great.”

The “Not So Good”

Every week I see new patients who have had complications with either scarring or pigment loss due to the older laser resurfacing (4 to 5 years ago) or  chemical peels (from even further back). In contrast, today’s “new” lasers for resurfacing are really laser scanners, using micro-pixels of laser energy to penetrate the skin. These lasers accomplish more than we ever gained for our patients with traditional laser resurfacing. The “old” resurfacing energy was not delivered in pixels, and it peeled away the skin surface. It was almost asking the body and the skin to do something that it really could barely do. The new fractionated lasers are much more gentle.

The “Truly Great”

I favor two choices today with fractionated, pixilated lasers.

  • Fraxel: We have used this treatment for several years. We use Fraxel laser treatments in Portland almost every day to treat the arms and hands. Fraxel, however, is not my choice for the face, neck and chest as none of my patients really ever saw enough in any single given treatment to make them truly excited.
  • SmartXIDE DOT: This is my choice for the face, and those stubborn lip lines. DOT therapy is fractionated carbon dioxide resurfacing. As I write this, we are preparing for a scientific presentation of our work with laser fractionated resurfacing over the last year. We are seeing a softening of unwanted lines along with skin surface tightening in areas like the neck line and eyelids.

There is a “price” to years of sun exposure. It is only somewhat fair that there is a price, so to speak, to repairing years of damage. With DOT, you will see a red pinkness that is noticeable for about 7 to 10 days. After about 2 weeks, everything should look wonderful and you should feel completely comfortable returning to your full social and work life.

I really believe that the best use of these lasers comes with the skill and knowledge from not just of a few procedures, but literally of hundreds of procedures. It is also helpful when the physician has experience in traditional resurfacing. Physician inexperience increases the risk factor for you as the patient, so choose wisely. In the hands of an experienced physician, this new generation of lasers is probably the best thing that’s happened to smooth away those lines and wrinkles.

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What Can You Do about Cellulite?

Apr 29th, 2010 by Dr. Key

Cellulite, Cellulite, Cellulite! It’s a cosmetic concern for almost all women, and despite all the “miracle” cures, it always seems like a cure is just out of reach. “What can I do about cellulite?” is number 1 on most of my patients’ list of questions to ask.

First a clarifying note on cellulite. Cellulite is the lumpy, bumpy, uneven skin texture that many women have on their thighs, hips and even abdomen. Occasionally, I’ll have a patient come in and say, “I want to have this cellulite gone,” but really what they’re talking about is excess fat. Treatments to slim down an area of the body are plentiful – in fact I offer several body contouring options – but cellulite has been a much tougher problem to tackle – until recently.

Treating Cellulite

There’s still no “magic bullet” for cellulite, and there never has been an FDA clearance of any treatment specifically for “cellulite.” Rather, the clearances are for the temporary improvement in skin lymphedema and fluid accumulation. I think that speaks to just how challenging it is to treat cellulite successfully.

So the best method we have for cellulite treatment today? I use a combined treatment approach that starts with SmoothShapes, which by itself takes too many treatments and just isn’t enough for greater changes. Then, I add in Thermage Body treatments, which achieve deeper tissue effects. This combined method has delivered cellulite relief for many of my patients.

A Note on Seeing Your Results

My practice has been involved in a large number of cellulite trials, and the real challenge in treating cellulite is in proving your results with decent and I would use the word “real” photography. If you are thinking about a cellulite treatment but the provider doesn’t have a dedicated photography room with the ability to shadow the skin contours from above and the sides, then you are probably wasting your time and money. A sincere effort needs to be made by any Portland dermatologist or skin treatment specialist to document what you really look like beforehand so you know the treatment worked, because often 100% cellulite removal simply is not possible.

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Not Younger, Just Better…and Natural!

Apr 21st, 2010 by Dr. Key

When my patients come to me it really is not about “looking younger.” No one really asks that, but most say, “I would just like to look better.” So how do you make that happen?

One way is with injectable soft tissue fillers. These wrinkle erasers produce immediate results, so my patients can hold up a mirror right after treatment and say, “Wow! That’s amazing!”

All of us age differently, but one of the most common things I hear from my Portland dermatology patients is, “I just look tired, but I’m not.” In fact I’ve seen several patients in their 30s in the past week who said this exact thing. The concern they were having was shadowing and subtle loss of volume in the cheeks just beneath the eyes.

In the cheeks, all of us begin to lose that subtle “Flare” that is not fullness, but broadens the cheeks, and that most importantly lifts, and I mean “Lifts” with a capital L, the cheeks. As we age, we lose that precious fullness and volume that supports the lower face.

This loss of volume can be improved with injectable fillers. Injectables first of all are not BOTOX. BOTOX just paralyzes muscles, has been around about 20 years, and basically is nice, but just keeps us from squinting, frowning, and smiling too hard. Injectable fillers, if we make the right choice, can give us back what has been lost.

The most natural of all fillers, of course, is your own fat, but fat is harder to work with and far more unforgiving. I have done fat transfer injection for over 20 years, and the results can be truly great, but it’s often easier to use hyaluronic acid fillers. Hyaluronic acid is a complex sugar starch that fills our skin, that holds most of the water in our skin, and is the structural support within which collagen grows. Common injectable brands you may have heard about include Restylane and JUVÉDERM, or their slightly denser formulations known as Perlane and JUVÉDERM Ultra Plus. There certainly are others, and we use them all, such as Evolence, Radiesse, and Sculptra.

Injectable treatments are comfortable and take only minutes. We use a method known as injectional lifting that creates subtle results with much more gain correction, lifting the cheeks, filling and lifting the lips and the area around the mouth, and correcting deepened marionette lines. How long these injectables last depends on the area being treated, but some areas like the cheeks can see results that last for years!

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Inches Away with ZERONA!

Apr 16th, 2010 by Dr. Douglas Key

All of the old rules are out the window when it comes to losing those unwanted inches. We are not talking a subtle change – think 3 to 5 inches or even more. So what’s the secret? ZERONA. There is plenty of buzz around Portland about ZERONA, and specifically about combining this revolutionary body contouring treatment with SmoothShapes for cellulite reduction.

ZERONA is not liposuction, but a new frontier in laser medicine. This frontier uses light and lasers that flow gently through your skin, enter fat cells to open up membranes, and let the fat flow out of cells and leave your body. The treatment protocol is 6 non-invasive treatments over 2 weeks – then you sit back and watch as your body slims itself down naturally.

The Science behind ZERONA

If you’re thinking about having ZERONA in Portland, know that there’s a wealth of science to back up the results. In a study submitted by ZERONA to the FDA, over two thirds of patients lost over 3 inches in the combined measurement of their hips, waist and thighs. This is compared to no change in body size in the control group.

I tell my patients that ZERONA and SmoothShapes combine the science of transporation (the cross cell membrane movement of fat) with photomodulation (the noninvasive breakup of fat within cells with low level laser energy). In a single treatment session these light energies are combined to treat the abdomen, waist, hips, and upper thighs. It is important to note that ZERONA and SmoothShapes do not remove fat cells as laser lipolysis and liposuction do, but are fundamentally different. They cause fat to leave the cells and, in turn, leave the body.

When Is Liposuction Necessary?

Even though ZERONA is a revolution in body contouring, there’s still a place for more traditional liposuction procedures. At my practice, we tell patients that if ZERONA and SmoothShapes aren’t achieving their desired results, then they can pursue body contouring with Body-Jet and CoolLipo lasers to permanently remove excess fat cells. This is a particularly effective method for women and men who are seeking more extensive contouring.

Do you have questions about ZERONA? Ask away – I look forward to hearing from you!

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Choosing a Cosmetic Laser Medicine Provider: 3 Rules

Nov 6th, 2009 by Dr. Key

In my previous post (here), I emphasized that not all laser treatment providers are created equal, and now I want to share my 3 rules for how you can choose a good one.

Whenever you are considering a treatment center, first ask the question, “Who’s in charge and what is their background?” Are they board certified in plastic surgery or dermatology? Do they perform surgery, but their nurses do most of the laser and injectables treatments? Are they a family practitioner who’s taken a few weekend courses in cosmetics and now has a fancy new laser they want to try out?

While the possibilities may seem endless, the answers you want are really simple:

  1. Full time dedication to aesthetics, and board certification from a core of cosmetic knowledge and skill, dermatology, or plastic surgery specialties. Cosmetic laser medicine is not a part time deal. There is far too much to understand and be experienced in, so the dermatologist or surgeon ultimately responsible for your care must be able to see what the possibilities of minimally invasive or noninvasive laser medicine are all about. It’s not enough to see lasers as a “secondary” or “backup” treatment to surgery, or worse yet as an “additional revenue stream.”
  2. Beware the words “Laser Certified” or “Laser Trained Technician.” This type of certification and training can be obtained very easily without the years of in-depth education on patient health and anatomy that a medical doctor possesses. If something goes wrong, and it inevitably does at treatment centers with these types of practitioners, they have practically no way of knowing how to fix the situation, and you could be harmed as a result.
  3. Get Detailed Photos Upfront. If a practice doesn’t take detailed digital photos before you begin treatment (and I mean state of the art, high resolution photography, in a room exclusively dedicated to recording pre-procedure images), it’s time to get out the door as quick as you can, because you are quite literally throwing your money away. That office, spa, or whatever, really doesn’t care about their “after” procedure results, and I mean for everything, including BOTOX®, Restylane®, JUVÉDERM®, rosacea light treatments, acne treatments and more.

I hope these rules for picking laser skin care centers in Portland, Oregon are helpful. If you’ve had disappointing results from a prior laser treatment, what other things would you suggest people look out for?

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