The Skinny on Cosmetic Skin Treatments
by Constance Young

With TV's ubiquitous extreme makeover programs and popular dramas like "Nip and Tuck" that dramatize the lives of trendy plastic surgeons, viewers are getting a crash course in cosmetic skin treatments just from watching TV. But like an empty Botox® injection, something is missing. These TV makeovers usually dramatize pricy face and brow lifts, liposuctions, chemical peels, collagen implants, and Botox injections, but barely touch on, or clarify, the wide and bewildering array of other minimally-invasive, and sometimes less expensive skin treatments. Read on and we'll cover these and other procedures offered in the Hudson Valley and elsewhere by Board-certified dermatologists and cosmetic surgeons as well as aestheticians under physician supervision.

This article will focus on facial skin and leave "tummy tucks," breast augmentations, nose jobs and the like for another time. We'll also focus on cosmetic (elective) procedures which are usually not covered under most insurance plans. As there are probably more skin treatments to choose from than lipsticks lining supermarket shelves, getting worthwhile, not to mention relatively trouble-free, skin improvement for your dollar can be a challenge.

The skin's structure
The skin is composed of several layers. The outermost layer, the epidermis, lies above the skin's thickest layer, the dermis. The dermis, which is held together by the protein collagen, supports the epidermis and gives it durability. The epidermis itself consists of several layers. The most superficial of these is the stratum corneum, which covers and protects the layers beneath and keeps the skin from drying out. The stratum corneum measures only about the thickness of a piece of Saran Wrap and consists of dead skin cells within a matrix of natural oils produced by cells lying within the deeper layers of the skin. Skin oils keep the skin soft, smooth and elastic, and when these protective oils are lost, or when water escapes, the skin dries out.

Rub it on
A number of creams and lotions can be rubbed onto the skin for surface repair--to soften imperfections such as fine lines and give the skin a smoother fresher look. These topicals, which should not be confused with more invasive chemical peels, include Retin-A® and glycolic acids. Retin-A (generic name: retinoic acid) is a vitamin-A-enriched cream that gives a mild, superficial peel of the outer layer of the skin and alters the cellular metabolism of the skin's surface. Glycolic acids, which are natural fruit substances blended into facial preparations, eliminate rough or dried surface skin. Neither treatment can remove deep scars or prevent aging and both offer less dramatic results than chemical peels or surgical approaches like dermabrasion. A related, even milder product, Renova®, is Retin-A mixed with an emollient cream.

Retin-A and the strong glycolic acids are available by prescription. These treatments are also sometimes used as preparation for facelifts or other complex procedures. For example, Retin-A can prepare the skin for skin resurfacing with peels and lasers because it thins the skin's outer layer, allowing the acid solutions used in chemical peels to penetrate more evenly. Because it thins the skin, people using Retin-A or Renova must use a sun block when going outdoors. Side effects such as temporary skin irritation and redness can be remedied by using milder formulas.

A number of spas and other healthcare facilities in the area offer these and related surface skin treatments as part of their package. According to Janice Di Giovanni, manager of Absolute Laser in Rhinebeck, their aestheticians do retinoic acid peels, glycolic peels and apply "a deep cleaning papaya enzyme mask," among other procedures. She adds that their aestheticians were trained by Board-certified dermatologist Patrick Bitter, M.D. and plastic surgeon, Stephen Mulholland, M.D. to perform their specialty procedures.

Skin "resurfacing"
Skin resurfacing is a term applied to several techniques that change the surface texture and appearance of the skin, to remove precancerous lesions, and to treat other medical conditions. The most common resurfacing techniques include chemical peels, dermabrasion (dermaplaning), and laser resurfacing. Variations include microdermabrasion and cold ablation.

Be aware that resurfacing procedures can lead to infection and scarring, prolonged redness and changes in skin coloration. According to dermatology's largest specialty group, the American Society for Dermatologic Surgery (ASDS), many skin procedures now offered at spas, salons, and "walk-in" clinics should be performed only by a physician or non-physician under direct physician supervision. These include chemical peels, lasers or light used for hair removal or skin rejuvenation that affect deep skin layers, and Botox injections. The Society cautions that non-physicians may be unable to diagnose serious and possibly life-threatening skin conditions such as skin cancers. For best results, anyone considering a cosmetic skin treatment should ask questions of or about the person who will be doing the procedure and learn how the procedure will be performed (see suggestions in the sidebar).

And what about aestheticians? Aestheticians are trained to "give treatments to keep skin healthy and attractive" and also to carry out certain cosmetic skin treatments. Their licensing body is the Board of Cosmetology and Barbering, who license them to "practice the cleansing, stimulating, manipulating and beautifying of skin, with hands or mechanical or electrical apparatus or appliances." They cannot prescribe medications or provide medical treatments in the same manner as a dermatologist.

Chemical peels
Chemical peels are skin resurfacing techniques that employ a variety of caustic chemicals, area by area, to destroy skin layers. Depending upon the strength of the chemical, peels can be superficial (affecting only the upper layer of the skin), medium-depth, or deep. Superficial peels may be used to treat fine wrinkles, sun damage, acne, and the chronic facial dermatitis called rosacea, while deep peels are generally employed for the most severe wrinkling and sun damage.

Peels often cause some degree of pain, depending on depth, and may be done while under general anesthesia or with local anesthetics combined with sedatives. About a day after a superficial peel, the skin will turn faint pink to brown, and dead skin will peel away over the next few days. Deep-peeled skin will turn brown and crusty and may swell and ooze. Some chemicals used in deep peeling can affect the functioning of the heart.

Because chemical peels and other skin resurfacing techniques can precipitate herpes simplex infection (the kind of herpes related to cold sores and not the sexually-transmitted variety), people with a history or herpes infections are given antiviral drugs to prevent a recurrence.

Dermabrasion
Dermabrasion is a surgical skin resurfacing procedure in which the physician planes or sands the skin to remove skin layers using a power-driven hand-held abrasive device that has an end piece consisting of a serrated metal wheel, a small wire brush, or a diamond-impregnated grinding wheel. Some doctors prefer to abrade the skin by hand, using an abrasive pad. Dermabrasion is used primarily to treat acne and other scarring; for tattoo removal; and to treat wrinkling. It could be performed in an outpatient clinic or hospital under general anesthesia. For small skin areas, local anesthesia may be preferred.

Following the procedure, which usually heals in a week or more, an ointment is applied and the wound covered with a dressing and mask. Ordinarily, the dressing is removed after 24 hours and ointment reapplied for a number of days. There may be itching and pain and therefore pain medication or steroids may be given during the first few days to reduce swelling. Dermabrasion also can precipitate latent herpes simplex infection.

• Microdermabrasion, which uses tiny crystals to remove surface skin layers, is a less risky abrasive procedure with a more rapid recovery time. It is promoted to correct fine lines, superficial scars, sun-damaged skin and "age spots." While microdermabrasion causes less facial redness and is easier to perform than dermabrasion, multiple treatments are required and its effect on appearance may be minimal. The procedure is almost painless, however, and does not usually require anesthesia.

Laser resurfacing
Many different types of lasers are used in skin treatments. They can be used as knives to make cuts that do not bleed; to smooth skin wrinkles; or among other procedures, to remove skin moles or tattoos. The term "laser" is an acronym that stands for "light amplification by stimulated emission of radiation," which although not easily understood by the layman, describes precisely how a laser works.

In simple terms, laser equipment produces and amplifies light that has unique properties differing from normal light. Laser light contains only one specific color, or wavelength of light, and the light that is released is "organized," extremely strong, and highly directional. Compare this with the beam of a flashlight, which is relatively weak and diffuse and consists of varying colors and wavelengths.

Lasers are usually named after the medium used to generate the light. CO2 lasers are used most often on the skin for sun-damage, wrinkles or lines, scarring, and to correct uneven pigmentation. The Plastic Surgery Center of Kingston, one of the facilities in the area that performs a CO2 laser "peel" to resurface the skin, explains on its website that the laser works by vaporizing the upper layers of damaged skin at controlled levels of penetration. The procedure takes from a few minutes to one hour depending on the extent of skin being treated, and is usually done in an outpatient facility. More than one session is often needed.

Side effects may include temporary swelling, discomfort, skin lightening in treated areas, acute sun sensitivity, sensitivity to makeup, or pink discoloration or redness lasting up to 6 months. People undergoing the treatment are usually back at work within two weeks. Risks of laser treatments include burns or injuries caused by laser heat, scarring, abnormal changes in skin color, or flare-ups of herpes or other viral infections.

Non-ablative lasers
"Non-ablative" means that no cutting is involved (ablation means to cut surgically). Several different types of lasers are used to improve wrinkles without removing or injuring the skin layers. These non-invasive methods focus on tissues beneath the skin. Non-ablative laser light treatments require little or no recovery time. Dermatologist Roy G. Geronemus, M.D., director of Laser & Skin Surgery Center of New York in Manhattan, uses what he calls "dynamic cooling" with a specially designed Nd:YAG laser. A cryogen cooling spray is used to protect the epidermis during the treatment, sparing it from heat damage or injury. In the meantime, the dermis is supposed to absorb the heat of the laser light, without removing any tissue. The controlled thermal effect at the deeper layers is supposed to stimulate new collagen formation to tighten underlying skin, and improve fine lines and loose skin without inducing a superficial burn or skin injury.

In our areas as well, doctors and aestheticians are using similar non-ablative techniques. In addition to his other procedures, Board-certified dermatologist A. Neal Gregory, M.D., who practices at Upper Hudson Valley Dermatology (UHVD) in Red Hook, uses what he calls a Candela laser, which also uses cryogen cooling and short pulses to achieve results without the purple blotches or redness caused by bleeding under the skin that occurs with other lasers. Dr. Gregory says that he is a Mohs Micrographic Surgeon, which allows him to remove skin cancers under microscopic examination to get to the "roots" of the cancer.

Other minimally invasive techniques
Although these treatments don't produce the dramatic effects of traditional therapies like chemical peels, surgery and traditional lasers, they are typically less expensive than surgery and don't require long recuperative time. However, they usually require several treatments.

• Pulsed light and radiofrequency. Ms. Di Giovanni of Absolute Laser in Rhinebeck says that their aestheticians do a procedure called a FotoFacialTM which, she states, spares the epidermis while heating up the dermis. The procedure combines an intense one-second pulsed light combined with radio frequency waves. She explains that the procedure heats up redness or dark spots caused by sun damage and brings the pigment to the surface over the course of the week. She also says that it speeds up collagen production to tighten and soften lines. Another effect, that it destroys hair follicles, might be considered either negative or positive. Side effects could include a superficial burn, particularly in bony areas, and loss of pigment. The trick, says Ms. Di Giovanni, is knowing whom to treat, and she adds that their center is very "particular in that regard." (Selecting the best skin treatment depends on knowing a person's skin type, so discerning that skin type is essential.)

• Cold ablation (coblation). In one newly developed cold ablation procedure called coblation, a multi-electrode radiofrequency device uses a cool process to remove tissues with minimal thermal injury. During the procedure, a metal stylet is used to apply saline to the skin, which conducts a cool electrical current across the treatment area. Although the procedure resurfaces the skin, it also is supposed to be able to heal wounds and scars safely and relatively comfortably, and erase fine wrinkling with little post-operative pain and few side effects.

• Other treatments. In other light-based rejuvenation techniques that have evolved as an outgrowth of NASA research designed to help plants grow in space, people sit in front of an array of blinking lights for a few minutes. Also, both electrical currents (iontophoresis) and sound waves (sonophoresis) can be used to facilitate greater penetration of vitamins A, C and growth factor into the skin and thus stimulate thickening of the skin, improve collagen production, control pigmentation, and restore normal blood flow and oxygen to the skin.

A new version of an old standby
UHVDs dermatologist Dr. Gregory also performs what he calls "a thread lift." This new non-invasive version of a face lift is done under local anesthesia using absorbable surgical threads, Dr. Gregory explains. Dr. Gregory and other UHVD dermatologists also perform other surgical procedures including liposuction, Botox injections, and the use of cosmetic fillers (using collagen and other synthetic fillers).

There are an unknown number of new skin procedures under development; and by the time this article goes to press, there may be even more. Most of these are so new that there are few practitioners skilled in practicing them, nor many patients who can vouch for them.

The old "tried and true"
Botox (botulinum toxin Type A) is a drug based on the bacteria Clostridium botulinum, that causes food poisoning. The best-known use is of Botox is cosmetic, to block nerve impulses that trigger muscle contractions, and in so doing reduce facial lines on the forehead, between the brows and around the eyes. Botox is also used for many medical conditions, including crossed eyes, uncontrollable blinking, to ease low back pain, even to reduce excessive sweating.

Other more invasive plastic surgeries are used to mold or reform the face. Liposuction, also known as Iipoplasty, is used to remove fat deposits. You can learn more about other various forms of face, brow and eye lifts tt by contacting The American Society for Aesthetic Plastic Surgery.

Decision-Making Tips
From the American Society for Dermatologic Surgery

Here's what you need to know before deciding on a cosmetic skin procedure and some questions you should ask.

• How many times has the person performed your procedure?
• Is the person doing the procedure board-certified, licensed, or otherwise qualified in cosmetic skin procedures?
• Ask to see before-and-after pictures.
• Ask to speak to someone who has had the procedure.
• Ask about any possible side effects.
• Ask how to know if you are the right person for that particular procedure.
• If the procedure is not being performed by a physician make sure that a physician is available or on-site and will be able to respond promptly to any questions or problems that may occur while the procedure is being performed.
• Is the laser being used right for your skin type?
• Ask to have a test patch if you have sensitive skin or are unsure about a procedure.
• Don't wait to call if you experience discomfort or discoloration after a procedure.