PALM BEACH

PERFECT SKIN

The Quest for Ideal Skin Health & Beauty

KENNETH BEER, MD, FAAD

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DISCLAIMER
The information contained in this book represents the opinions of the author and
should by no means be construed as a substitute for the advice of a qualifi ed medi-
cal professional. The information contained in this book is for general reference and
is intended to offer the user general information of interest. The information is not
intended to replace or serve as a substitute for any medical or professional consulta-
tion or service. Certain content may represent the opinions of Kenneth Beer, MD,
FAAD based on his training, experience, and observations; other physicians may have
differing opinions.

All information is provided “as is” and “as available” without warranties of any kind, ex-
pressed or implied, including: accuracy, timeliness, and completeness. In no instance
should a user attempt to diagnose a medical condition or determine appropriate
treatment based on the information contained in this book. If you are experiencing
any sort of medical problem or are considering cosmetic or reconstructive surgery,
you should base any and all decisions only on the advice of your personal physician
who examined you and entered into a physician-patient relationship with you.

This book is designed to provide information of a general nature about cosmetic
procedures. The information is provided with the understanding that the author
and publisher are not engaged in rendering any form of medical advice, profes-
sional services, or recommendations. Any information contained herein should not
be considered a substitute for medical advice provided person-to-person and/or in
the context of a professional treatment relationship by qualifi ed physician, surgeon,
dentist, and/or other appropriate healthcare professional to address your individual
medical needs. Your particular facts and circumstances will determine the treatment
that is most appropriate to you. Consult your own physician and/or other appropri-
ate healthcare professional on specifi c medical questions, including matters requir-
ing diagnosis, treatment, therapy or medical attention. Any use of the information
contained within is solely at your own risk. MDPress, Inc. assumes no liability or re-
sponsibility for any claims, actions, or damages resulting from information provided
in the context contained herein.

ISBN: 0-9748997-3-9

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copyrighted property of Kenneth Beer MD, FAAD. Reproduction, redistribution, or
modifi cation in any form by any means of the information contained herein for any
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Acknowledgements

I would like to thank my wife Jennifer, my sons Jacob

and Michael, and my daughter Gillian for putting up with

me during the writing of this book. You have been a

source of inspiration with each passing day, and for this I

am eternally grateful. To my patients, thank you for your

faith in me and my work. I hope that I may continue to

help you, with the very best resources available, in your

quest for beauty and skin health. A special thanks to the

MDPublish team for their skillful collaboration.

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To my wife,

with love, honor, and admiration.

To my sons and daughter,

with pride in everything you do

and everything you will become.

To my parents

Myrna and Daniel Beer, M.D.,

for giving me the encouragement

to exceed my own dreams.

To my colleagues and friends,

with gratitude for the lessons

you have taught me along the way.

To my staff,

who as a team have taught me

to become a better dermatologist.

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Contents

Introduction 13

Chapter

The Structure of the Skin & How

This Changes with Aging

Skin Overview

Under the Microscope with Normal Skin

Skin Structure

How Changes in Skin Structure
Lead to Wrinkles

Fine (Superfi cial) Wrinkles

Deep Wrinkles

Creases

Dynamic Wrinkles

Static Wrinkles

Skin Through the Ages

Chapter

The Sun & Your Skin

Preventing Sun Damage

Sun Protection Factors

Selecting an SPF

Sun Protection Checklist

What to Do If You Get Burned

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Chapter

Skin Maintenance & Improvement:

Damage Control & Repair

Advancements in Cosmeceutical Skincare

Moisturizers

Cosmeceutical Creams

Glycolic Acid

Vitamin C

Growth Factors

Antioxidants

The Palm Beach Peel

System

The Palm Beach Peel

Steps:

Exfoliation, Nourishment, Cleansing,
Moisturizing & Exfoliation

Skin Nourishment

An Overview of Cosmeceuticals

Chapter

A Lifetime of Perfect Skin: Why You

Need a Cosmetic Dermatologist

What Is a Cosmetic Dermatologist?

Know Your Skin Type

Fitzpatrick Classifi cation

How to Choose an Ideal Skin Regimen

Before You Buy

The Basics: Six Steps for Ideal Skin

Seasonal Skincare

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Chapter

Maintaining Clear Skin

When You Have Acne

Understanding Acne

Oral Acne Treatments

Accutane

and Its Generic Versions

Hormonal Therapy

Topical Acne Treatments: Prescription,
Over-the-Counter Products, Light Based
Treatments, and Daily Care for
Acne Prone Skin

A prescription from a dermatologist

Non-prescription options

Light based treatments

Photodynamic Therapy (PDT)

Daily Care for Acne Prone Skin

Dr. Beer’s Daily Anti-Acne Regimen

Chapter

Common Conditions That Interfere

with the Perfect Skin Plan: Rosacea,

Sensitive Skin, Eczema, Psoriasis

Rosacea

Daily Care for Rosacea Prone Skin

Sensitive Skin

Eczema (Atopic Dermatitis)

Psoriasis

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Chapter

Lasers & Light Sources:

The New Waves

Lasers for Skin Rejuvenation

Non-Laser, Light Based Rejuvenation:
Intense Pulsed Light, Radiofrequency,
Photodynamic Therapy, LED, and Fraxel

™

Intense Pulsed Light 90

Radiofrequency Waves

Syneron ELOS

™

System

Photodynamic Therapy

LED Technology

Fractional Resurfacing Including Fraxel

™

Summary of Lasers, IPL, and LED Devices

Combination Treatments That Work
in Conjunction with Laser, LED & IPL

Chapter

All About Botulinum Toxin

What Is the Difference Between
Botox

, Myobloc

, and Reloxin

How Botulinum Toxins Work

After an Injection

102

How to Avoid Problems with Botox

103

Limitations of Botox

: Where Fillers

Are Needed

103

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Chapter

Fillers for Facial Rejuvenation

105

A Brief History of
Soft Tissue Augmentation

106

How Fillers Work

107

How Long Do Fillers Last?

108

What Are the Side Effects?

108

How Long Is the Recovery?

109

What Goes Where?

109

Fillers in Detail

110

Hyaluronic Acids

110

Restylane

110

Hylaform

and Hylaform

Plus 112

Captique

™

112

Juvederm

112

Collagens 112

Zyderm

and Zyplast

113

Human Collagen

113

CosmoDerm

/CosmoPlast

113

AlloDerm

and Cymetra

114

Products Derived from Your Body

114

Isolagen 115

Volumizers: Long-Term Soft
Tissue Augmentation

115

Sculptra

115

Facts About Fat Transfer 117

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Semi-Permanent and Permanent Fillers

117

Artefi ll

117

Radiesse

™

118

Injectable Liquid Silicone 119

The Spectrum of Dermal Fillers

120

Chapter

Holding on by a Thread

121

Contour Threadlift

™

122

Who Is a Good Candidate?

122

Who Is Not a Good Candidate?

122

What Areas Can Be Lifted?

123

How Is the Procedure Performed?

123

What to Expect After the Procedure

123

How Long Do the Results Last?

124

Chapter

Tumescent Liposuction

125

How Safe Is Liposuction?

127

Who Is the Ideal Candidate?

128

The Liposuction Procedure

130

What to Expect After Liposuction

130

Fat Transplantation

131

The Fat Transfer Procedure

132

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Chapter

Eradicating Veins, Unwanted Hair,

& Stretch Marks

133

Leg Veins

134

Hair Reduction Strategies

135

Hair Removal Methods

138

Laser Hair Removal

140

The Laser Hair Removal Procedure

141

Improving Stretch Marks

143

Chapter

Advances in the Diagnosis

& Treatment of Skin Cancers

145

Early Detection

147

Actinic Keratoses

149

Origins of Actinic Keratoses

149

Symptoms of Actinic Keratoses

149

Types of Actinic Keratoses

150

Treatment of Actinic Keratoses

150

Basal Cell Carcinoma

151

Origins of Basal Cell Carcinoma

151

Symptoms of Basal Cell Carcinoma

152

Types of Basal Cell Carcinoma

152

Treatment of Basal Cell Carcinoma

153

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Squamous Cell Carcinoma

153

Origins of Squamous Cell Carcinoma

154

Symptoms of Squamous Cell Carcinoma 154

Types of Squamous Cell Carcinoma

154

Treatment of Squamous Cell Carcinoma

155

Melanoma

155

The Origin of Melanoma

155

Symptoms of Melanoma

156

Four Basic Melanoma Types

156

Treating Melanoma

157

Non-Surgical Treatments for Skin Cancer

157

Surgical Approaches to Skin Cancer

158

Excisional Surgery

159

Electrodessication and Curettage

159

Mohs Surgery

160

In Summary

162

Chapter

What the Future Holds

in the Quest for Perfect Skin

163

Glossary

166

Resources

180

Index

181

About the Author

184

Appendix

185

Order Form

190

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Introduction

Perfect skin is a goal that many seek but few attain. Perfect

skin must be healthy on the inside as well as on the outside.

The outer (epidermal) layers should be blemish-free and

radiant, the middle layers resilient, and the inner layers must

provide support, structure, and nutrition. Any defi ciency in

this triad will result in skin with sub-optimal appearance

and wellness. Some people are born with perfect skin.

Others need help from cosmetic dermatologists and plas-

tic surgeons. This book will help you navigate your path to

perfect skin. We will discuss skin treatments and products

designed to help you look your best as well as information

and some common problems that may be barriers to your

goal.

The renaissance underway in cosmetic dermatology

makes this an ideal time to begin your quest for perfect skin.

Presently available techniques, procedures, and products can

rejuvenate your skin while avoiding the risks and downtime

of invasive surgery. Non-invasive procedures are constantly

improving, and we will review what is presently avail-

able and glimpse into the near future. We will discuss skin

function when it is healthy and present information about

common skin diseases and problems. To help you choose the

best skincare products for your skin, information about cos-

meceuticals and prescription skincare products is presented.

If, after reading this book, you can make educated decisions

about what is and is not right for your skin and know what

questions to ask your dermatologist or plastic surgeon, I will

have succeeded in my goal for writing it.

In order to provide some background, let me offer a brief

biography: I attended medical school at the University of

Pennsylvania School of Medicine, and after completing one

year of internal medicine I spent four years at the University

Introduction

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of Chicago in a dermatology residency and dermatopath-

ology fellowship. During those four years, I learned most of

what I know about the skin. My pathology training taught

me about the microscopic structure of the skin and, dur-

ing my fellowship, I began to wonder about how to create

healthier skin at a microscopic level and more youthful

appearing skin at a clinical level. I spent years learning how

to diagnose and treat melanomas, basal cell carcinomas, and

squamous cell carcinomas. The transformation from damaged

cell to pre-cancerous cell to cancer fascinated me, and I

studied the prevention of this process. As I learned more

about skin cancers, I realized that the development of these

lesions and the process of aging is closely interrelated and

that preventing skin cancers could also help the skin appear

more youthful. In my dermatological surgery practice, I

specialize in cosmetic dermatology as well as in the diagno-

sis and treatment of skin cancer ; I enjoy both. I teach at the

University of Miami in the Department of Dermatology, and

my research interests encompass both areas. The Cosmetic

Boot Camp—a course that I direct with Mary Lupo, M.D.—

keeps me on the “cutting edge” of the newest products and

procedures in cosmetic dermatology.

Some background about dermatology in general—and

cosmetic dermatology in particular—will help you to under-

stand the information contained in this book. Dermatology is

the ONLY branch of medicine dedicated to the skin. Derma-

tologists are physicians who have completed four years of

medical school (if they are medical doctors; there are also

osteopathic dermatologists who have not gone to medical

school). If they are Board Certifi ed by the American Board of

Dermatology, they have completed a year of internal medi-

cine, pediatrics, or surgery prior to spending three years

studying the skin at a university hospital where they are

supervised by other dermatologists. After this training, they

must pass a board certifi cation exam to state that they are

“Board Certifi ed by the American Board of Dermatology”.

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To maintain profi ciency, they must recertify at least every ten

years if they have completed their training after about 1992

(older dermatologists are exempted from this requirement).

Some dermatologists spend additional time completing fellow-

ships in dermatopathology (the study of the skin using a

microscope), dermatologic surgery, or pediatric dermatology.

Recently, there has been a proliferation of internists, family

practice doctors, gynecologists, and a host of other practi-

tioners who call themselves skin specialists, cosmetic

surgeons, or even dermatologists without being board certi-

fi ed by the American Board of Dermatology. Unfortunately,

this practice is not closely regulated in many states, but

patients should be aware that these individuals do not

have the training or experience required to take care of

your skin.

Dermatology experienced a renaissance from the days

when it was dominated by acne and warts. Part of this revo-

lution in dermatology was actually brought about by man-

aged care and healthcare reform. As insurance companies

moved skin cancer surgery from the hospital to the derma-

tologists’ offi ces, the specialty became primarily surgical.

Dermatologists became more knowledgeable about skin can-

cer reconstruction. This experience prompted interest and

research into lasers, fi llers, liposuction, and other cosmetic

procedures that could also be performed in the offi ce. The

evolution of surgical dermatology occurred as I was training.

During my residency I became interested in research, skin

cancer reconstruction, liposuction, lasers, chemical peels,

soft tissue augmentation using collagen, fat, and hyaluronic

acids. How much the fi eld of dermatology has changed is

demonstrated by Medicare statistics which show that the

majority of skin cancers treated in the United States are now

treated by dermatologists.

Surgical dermatologists are represented by the American

Society for Dermatologic Surgery (www.asds-net.org), and

they are now known as Dermasurgeons. We have our own

Introduction

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PALM BEACH PERFECT SKIN

meetings, research, and journals. Dermatologic surgeons

differ from plastic surgeons (who specialize in procedures

such as hand reconstruction, facelifts, burns, and breast aug-

mentation) because we focus only on the skin.

Cosmetic dermatology has added several major prod-

ucts and procedures in the past few years, including novel

uses for botulinum toxins such as Botox

, Myobloc

, and

Reloxin®. Until recently, these proteins were used exclu-

sively for frown lines. Now they are used to treat wrinkles

of the chin, forehead, lip and to minimize crow’s feet, neck

bands and drooping breast skin. These toxins are used to

treat excessive sweat, headaches, and medical problems rang-

ing from back spasms to urinary incontinence. Revolutionary

fi llers such as Restylane

, Restylane

Sub Q, Perlane

, Sculp-

tra

, Hylaform

, Captique

™

, Hylaform

Plus, Juvederm

Isolagen, silicone and Radiesse

™

have expanded a universe

of fi llers once limited to collagen. New lasers, intense pulsed

lights, and radiofrequency devices including Thermage

and

Fraxel

™

, have opened up new possibilities for non-invasive

skin rejuvenation. Dermatologists and plastic surgeons are

just beginning to discover the full potential of these devices,

products, and procedures, and learning what can be accom-

plished when they are used together.

“The ‘injected facelift’ is now a foreseeable reality.”

Until recently a facelift was the best way to rejuvenate an

aging face. Now, novel techniques including fat transfer, soft

tissue fi llers, volumizers such as Sculptra

, lasers, and botu-

linum toxins can reverse the signs of aging without surgery.

The “injected facelift” is now a foreseeable reality. Suspension

sutures used to directly reposition the skin upward eliminate

the need for cutting with some patients. For others, there

will never be a substitute for a facelift but those numbers are

dwindling. Even for individuals requiring a facelift, the judicious

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use of lasers, fi llers, botulinum toxins, peels, and a good skin-

care regimen can ensure the best possible results.

Throughout the course of this book, I will identify trends,

treatments, and products that make sense. Thus, we will

discuss the rationale for what is used in cosmetic derma-

tology. My cosmetic dermatology practice draws upon a

palette from which I create an individualized program for

each patient based on their goals, tolerance for downtime,

and budget. Typical patients rejuvenate the outer layers of

skin with intense pulsed light, laser, chemical peels, and/or

topical treatments that include prescription and non-pre-

scription products. My patients with wrinkles due to muscle

activity (including frown lines and crow’s feet) get treated

with botulinum toxins such as Botox

. Wrinkles due to

loss of subcutaneous tissue are fi lled with hyaluronic acids

(including Restylane

, Hylaform

, Captique

™

, Juvederm

, and

others), Sculptra

, Radiesse

™

, collagen and/or fat transfer. I

perform body contouring with tumescent liposuction and fat

transfer. Lasers and intense pulsed light sources are utilized

to treat pigment irregularity, spider veins and unwanted hair

as well as to tighten the skin by rejuvenating the collagen

and elastic fi bers. Two new lasers are able to help success-

fully treat cellulite.

My book will also help readers to understand how the

skin functions when it is well and what happens when it is

diseased. I will discuss the structure and function of normal

skin and then contrast this to skin effected by acne, psoria-

sis, eczema, rosacea, skin cancer and other common skin

ailments. Hopefully, this will provide enough information to

enable you to have a meaningful discussion with your der-

matologist and to help you take better care of your skin.

Skincare products consume signifi cant amounts of time

and money. While some products are marketed by unscrupu-

lous means, others result from years of research and develop-

ment at companies with impeccable reputations and great

scientists. Frequently, it is diffi cult for consumers to tell the

Introduction

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PALM BEACH PERFECT SKIN

difference between these two extremes, and I will provide

some pointers in the skin product section.

My own product line began with a few glycolic acid

products, but expanded as it was embraced by my patients,

their friends, and their relatives. As the circle of users has

expanded, I have increased my offerings, which now include

the Palm Beach Peel

integrated product system. The goal of

my skincare system is to provide the type of skincare that

was, until recently, only available at a cosmetic dermatology

offi ce. With The Palm Beach Peel

, one can customize the

frequency and duration needed to peel, exfoliate, cleanse

and apply nutrients and vitamins to the skin. I continue to

change my products as newer research discovers better

ingredients. My ability to do this is one reason that I devel-

oped my own line of products.

Each patient who walks into a cosmetic dermatologist’s

offi ce wants to look his or her best. Whether in my offi ce or

in this book, it is my job to provide information about the

products and procedures that will help accomplish this goal

and to provide information about some of the obstacles that

can stand in your way.

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CHAPTER

The Structure of
the Skin & How
This Changes
with Aging

“In cosmetic dermatology,

a little knowledge will help you

to have a lifetime of perfect skin.”

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PALM BEACH PERFECT SKIN

In order to comprehend skincare products, and treatments

and the various conditions that affect the skin, it is necessary

to understand some basic skin anatomy. While it is not pos-

sible to compress three years of dermatology residency and

one year of dermatopathology fellowship into one book, it is

reasonable to get some insight regarding the basic structure

and function of the skin. This will help you understand why

a treatment such as a superfi cial chemical peel, which treats

the outer layers of the epidermal layer, will not have any

effect on deep wrinkles or creases. To improve blotchy skin

associated with sun damage (a frequent sign of aging), it is

important to know where the pigment causing the problem

resides so that appropriate care can be selected. Any laser,

medication, or cosmetic procedure that does not address the

part of the skin anatomy causing the problem is destined to

be a waste of your time, effort, and money.

Skin Overview

“There is a lot going on inside what appears to be a bland

organ system called the skin, which is the body’s shield

against a hostile environment.”

The skin is the body’s barrier; it defends against diseases,

environmental challenges, and infection. It helps to regulate

body temperature and contains a vast array of chemical mes-

sengers and hormones used to communicate with various

cells in the body. Every square inch of skin contains about 15

feet of blood vessels, 100 oil glands, and two different kinds

of sweat glands. As you can already see, there is a great deal

of activity within the skin.

The best way to appreciate the differences between old

skin and new skin is under the microscope.

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The Structure of the Skin & How This Changes with Aging

(Photo Gallery Page 1, middle) A photomicrograph of

new skin demonstrates skin with an organized outer (epi-

dermal) layer as well as collagen and elastic fi bers (the thick

pink layer) that provide structure and support. When these

fi bers are young and intact, the skin is elastic and devoid of

wrinkles. As the collagen and elastic fi bers degenerate, this

layer becomes thin and disorganized, and the skin begins to

wrinkle and sag.

From a microscopic perspective, we can begin to under-

stand how what goes on at a cellular level translates into

visible signs of aging and think about logical means of

reversing them. If we look at a deeper biopsy, (such as pho-

tomicrograph 10 normal skin, no sun damage ) subcutaneous

adipose (fat) is visible in the bottom parts of the biopsy. Fat

provides a source of energy storage, insulation, and also sup-

port for the contour of the skin. As this fat diminishes with

age, the skin loses volume, and deep creases will begin to

appear. Treatments aimed at restoring volume and replacing

fat must address these deep layers of the skin if they are to

succeed. Procedures or products designed to treat wrinkles

need to replace or replenish the collagen and elastic fi bers

of the middle layers. Improvements of the canvas (outer

layer of the skin) must alter the epidermis in a manner that

restores a more youthful structure.

A photomicrograph taken from aging skin demonstrates

skin that is older and sun damaged. The epidermis is only a

few cells thick (two cells in most of this image). It is easy

to see that this thin skin is going to be more susceptible to

damage such as tears. This thinning of the epidermal layer

will leave an aged appearance to the surface of the skin.

Beneath this ragged epidermal layer, the collagen is no

longer pink and organized but rather bluish and raveled.

Deeper still, we see that the adipose layer is thinner than

it was when the skin was younger. These changes in the

deeper layers and loss of skin elasticity correspond to a

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PALM BEACH PERFECT SKIN

southward drift of the face. They are also responsible for

producing wrinkles and creases around the mouth and jowls.

Procedures designed to tighten the skin, replace lost connec-

tive tissue, or renovate the surface of the skin must deal with

the anatomic changes visualized and discussed here to have

a chance of obtaining their objectives.

These photomicrographs graphically illustrate what hap-

pens to the skin as it ages. Products and procedures used in

cosmetic dermatology and plastic surgery promise to restore

youthful skin and frequently make claims that they will

repair damage due to aging. While these products (such as

Retin-A

) will actually cause the collagen and epidermis to

rejuvenate (this has been confi rmed with biopsies), others

simply prey on the quest for youth.

Under the Microscope

(Photo Gallery Page 1, top) The skin is only two cells

thick in areas, and the epidermal cells are disorganized. In

addition, the pink collagen that provides support for the skin

is thin. As support structures and epidermis thin, wrinkles

and precancerous growths develop.

(Photo Gallery Page 1, middle) This is in contrast to the

second photograph that demonstrates youthful skin which is

thicker and more organized.

My dermatopathology training solidifi ed my understand-

ing of the skin in health, in disease and in aging. I have

analyzed thousands of skin biopsies, each of which graphi-

cally reveals subtle changes that speak to the pathologist.

To a dermatopathologist, middle age is a transition between

organized and disorganized skin. Depending on the color of

the skin and the amount of sun damage that it has sustained,

biopsies performed during middle age have small precancer-

ous growths called actinic keratoses. These biopsies show loss

of thickness from the dermal layers, which translates into

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The Structure of the Skin & How This Changes with Aging

visible fi ne lines around the mouth and eyelids. Increased

pigment visible in biopsies at the base of the epidermal layer

(basal layer) is seen on the skin as “liver spots.” Clearly, what

we learn about the skin under the microscope has reper-

cussions for clinical dermatology in general and cosmetic

dermatology in particular.

As with other parts of the body, the skin can age at a

normal chronological rate (in which case people will appear

as old as they are), at an accelerated rate (in which case

they appear older than their years), or at a decreased rate

(in which case they appear younger than they are). The

pace of skin aging is determined by genetics, sun damage,

skincare, and many factors that are just now beginning to be

understood by dermatologists. I consider these issues when

designing a skincare program for my patients, and it is worth-

while to think about them when deciding which products or

procedures are worth trying on your skin.

Skin Structure

A rational approach to skincare and skin wellness

requires an understanding of the structure of the skin.

Beginning at the outer layer, the skin is comprised of:

1. Epidermis

2. Dermis

3. Subcutaneous tissue

The epidermal layer may be further subdivided into four sub-

layers. The outer layer, called the stratum corneum is com-

prised of dead skin cells. Basket weave in appearance, this is

the body’s shield and fi rst line of defense against dehydration,

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PALM BEACH PERFECT SKIN

infection, ultraviolet damage, and a host of other environ-

mental insults. Its health is obviously important not only for

how your skin appears but also for how it ages and functions.

Stratum corneum cells may be polished by microdermabra-

sion, chemical peels, topical medications, and cosmeceuticals.

Proceeding inward from the stratum corneum are three layers

of cells: the stratum granulosum, stratum spinosum, and basal

layer.

Cells in these layers are in a constant state of fl ux with a

28-day cycle for the bottom cells to reach the top layer. The

timing of the cellular cycle governs the frequency of many

procedures and treatments used in cosmetic dermatology.

For instance, there is no point in trying a skincare product

for less than one month if you believe it is going to rejuve-

nate the entire epidermal layer. Nor does it make sense to

have chemical peels several times per week as some overly

aggressive practitioners advocate.

The stratum spinosum and granulosum are the middle

epidermal layers that are the thickest portion of the epider-

mis. These layers give rise to skin cancers known as squa-

mous cell carcinomas. Deep to these layers is the basal layer

of epidermal cells. It is this layer that forms the boundary

between the epidermis on the outside of the skin and the

dermis on the inside. Basal cells are a frequent source of

skin cancers known as basal cell carcinomas, the most com-

mon of all skin cancers.

Scattered amongst the basal cells at about every eight

cells are melanocytes. These cells produce the pigment

known as melanin, which is the pigment responsible for

the color of your skin and hair (or in some cases where it

is responsible only for the color of the roots of the hair).

Melanocytes cause the age spots that appear on the face

and hands. They also allow the body to tan in an attempt to

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The Structure of the Skin & How This Changes with Aging

shield itself from ultraviolet (UV) radiation. Melanomas, the

most deadly form of skin cancer, result from melanin cells

gone awry.

Beneath the epidermal layer is the dermal layer (dermis).

The dermis contains collagen and elastic fi bers that provide

strength and support for the skin. Blood vessels and nerves

traverse the dermis as they provide the skin with oxygen,

nutrition, and sensation. Beneath the dermis and epidermis

lies the subcutaneous layer, comprised of fat and other sup-

port structures that form the layer between skin and muscle.

It is within the dermal and subcutaneous layers that wrinkles

and folds form.

Treatments for wrinkles and folds are designed to restore

collagen, fat, and other support structures that have been

lost. Injectable products designed to replenish the der-

mal and subcutaneous layers include collagen, Isolagen,

Restylane

, Perlane®, Restylane

Sub Q, Hylaform

, Hyla-

form

Plus, Captique

™

, Juvederm

, silicone, Radiesse™,

and Sculptra

. Insight into the structure and function of the

skin layers helps to understand just how critical the experi-

ence and training of the injecting physician are to successful

outcomes. The right products placed at the wrong level may

produce either no result or lumps and bumps. Treatments

such as Fraxel

™

and Thermage

use energy to tighten exist-

ing collagen fi bers and stimulate the formation of new ones.

Treatments and products that address facets of aging at each

layer of the skin, allow cosmetic dermatologists to produce

dramatic results.

The subcutaneous layer also contains hair follicles, sweat

glands, and a host of other important structures. Fat cells

(adipocytes) found in this layer are a rich source of mate-

rial used for soft tissue augmentation. Cells may be removed

from areas such as the buttocks, thighs, or abdomen and relo-

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PALM BEACH PERFECT SKIN

cated to the hands or face with dramatic results. Adipoctyes

are a rich source for stem cells that may one day provide

replacement tissue for any part of the skin that is defi cient

or diseased.

Deep within the subcutaneous tissue are the roots of the

hair follicles. These roots (or matrix cells) are the targets

for lasers and intense pulsed lights that treat unwanted hair.

Wavelengths and energies are constantly being improved to

more effectively target the matrix cells (located in a region

of the follicle known as the bulge) so that hair removal is

safer and more effective. Treatments for hair removal that do

not have the energy to reach this deep level have no chance

of success.

How Changes in Skin Structure
Lead to Wrinkles

Changes in the skin structure directly lead to visible changes

at the surface of the skin. As muscles frown and scowl, push

and pull the skin, wrinkles become etched into the face.

Botox

, now the most common cosmetic procedure in

America, relaxes these muscles, minimizing the appearance

of these wrinkles. Degeneration of collagen, and elastic fi bers

translates to the appearance of jowls and creases. Changes

at the microscopic level that result in alterations at the vis-

ible level may be repaired with fi llers including Restylane

Sculptra

, fat, collagen and others presently under develop-

ment. The best way to understand cosmetic products and

procedures is to fi rst understand the skin changes that they

are trying to reverse. To help with this understanding, I will

fi rst discuss the various types of wrinkles and damage that

effects the skin, and then present various ways to reverse

the damage.

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The Structure of the Skin & How This Changes with Aging

Fine (Superfi cial) Wrinkles

Etched in, superfi cial lines extend only to the upper der-

mis. They are typically caused by sun damage and smoking,

which accelerate the degeneration of collagen and elastic

fi bers. The best examples are the little lines around the

mouth that cause lipstick to bleed. Treatments directed at

fi xing superfi cial wrinkles must target the upper layers of

the dermis; if they affect the epidermis or deeper layers, they

will not be fruitful. Thus, when you are concerned about

these types of lines and someone recommends a superfi cial

chemical peel, you should understand that this most likely

will not be productive because it does not address the defi -

ciency at the dermal level. In contrast, appropriately selected

fi llers, medium strength chemical peels, and a few lasers will

act at the correct part of the skin to make a difference. They

are worth trying.

Deep Wrinkles

Deep wrinkles extend through the upper dermis into the

mid and lower dermis. Repairing these wrinkles requires

either a resurfacing procedure that will remove all of the

layers above the wrinkle or fi llers designed to replace the

support structures that have been lost. Fillers appropriate for

deep wrinkles might include hyaluronic acids, collagens, fat,

Sculptra

, and several others presently undergoing clinical

trials. Radiofrequency devices that stimulate fi broblasts to

produce more collagen and devices that tighten fi bers can

repair damage at this level.

Creases

Creases are caused by the loss of deep subcutaneous tissue. They

require more substantial replacement of volume. One good

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PALM BEACH PERFECT SKIN

example of these are deep smile lines. These are caused not

only by loss of subcutaneous tissue but also by the laxity of

the connective tissue above it. Repairing creases involves

replacing lost tissue with thick fi llers designed for placement

at a deep level. These include autologous fat, Restylane

Sub

Q, Juvederm

, Perlane

, or Sculptra

Dynamic Wrinkles

Wrinkles caused by muscle movement are entirely differ-

ent from those caused by loss of connective tissue. Without

an understanding of these differences or the tools to treat

them differently, attempts to correct them are destined to

be a waste of time and money. The best example of dynamic

wrinkles is a frown line. Frown lines are the most commonly

treated wrinkles and the only FDA approved indication for

Botox

. These lines are the result of a series of muscles

(known as the corrugator, procerus, and depressor supercilii

muscles) that pull on the skin. As the skin moves, wrinkles

are formed. It is easy to understand why botulinum toxins,

which inhibit muscle activity, are the perfect treatment for

these wrinkles. For this type of wrinkle, injecting fi llers with-

out a botulinum makes little sense because the muscle activ-

ity will simply continue to wrinkle and the frown line will

be back in short order. Thus, treatment of dynamic wrinkles

should involve Botox

, Reloxin

, or Myobloc

. Frown lines

are one example of the fact that the successful treatment of

wrinkles frequently requires multiple modalities.

Static Wrinkles

In contrast to wrinkles seen with movement, static wrinkles

are evident at rest. These will not be helped by botulinum

toxins. They require fi llers to replace lost volume, and/or

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The Structure of the Skin & How This Changes with Aging

treatment with radiofrequency, laser or chemical peels to

tighten the connective tissues. Static wrinkles are diffi cult to

treat but when they are correctly addressed, their resolution

yields the most rewarding changes in appearance.

Skin Through the Ages

The skin changes with age and the skin you had in your

childhood is signifi cantly different from the skin of your adult

years. Understanding the skin at various points in time will

help you to have the best possible skin at each stage of life.

Let us look at the skin during various times in life:

Childhood, Teens, and 20s—Protection, prevention, and

medication are the keys to success in these years. Parents

of young children need to be vigilant with sun protection

and discuss the risks of sunburns with children. Information

regarding protection from the sun may be found at the web-

site for the American Academy of Dermatology (www.aad.

org) as well as the Weather Channel (www.weather.com).

Teens should be responsible for their sun protection. Gentle

coaxing as well as additional information from parents may

be helpful (sometimes this must be tied to the car keys)

when trying to get teens to prevent skin cancers that are

decades away. Damage done during early years is especially

signifi cant for aging skin and skin cancers. Early intervention

and education can have the most impact on skin wellness in

later life.

Teenage years are typically the fi rst time that the hor-

mones responsible for acne begin to affect the skin. This

may require prescription medications as well as a discussion

about skincare and skincare products. A dermatologist can

be very helpful during these years. There are many newer

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PALM BEACH PERFECT SKIN

treatments for acne including laser, IPL, and photo dynamic

therapy, in addition to more traditional treatments such as

topical and oral medications. The Palm Beach Peel

Exfolia-

tion Pads can help to unclog pores.

30s—The 30s are the branch point in the life of your skin.

The early 30s are a continuation of the 20s—basic skincare

with some focus on prevention and early treatment. By the

age of 35, however, most people hit a dermatologic (and met-

abolic) wall. The exact age that this transformation occurs is

not etched in stone, and it depends on genetics, health, skin-

care regimen, and external infl uences such as smoking, sun,

and stress. Skin color also plays a role, as darker skin tends to

look better at a given age than lighter skin.

How do you know when you hit the transition point?

When you begin to notice infomercials for age defying diets

and skincare programs you have begun middle age for the

skin. Once this occurs, the fi ght against aging begins in

earnest.

During the 30s good skincare includes visits to the

dermatologist for rejuvenation and prevention. This may

consist of chemical peels or intense pulsed light. Topical

medications such as Retin-A

or Avage

may become part

of your daily routine. Skincare products containing antioxi-

dants such as vitamin C and green tea, as well as exfoliation

products (such as The Palm Beach Peel

Home Microderm-

abrasion system) are added to your skincare regimen. Injec-

tions at a dermatologist’s offi ce with Restylane

, Perlane

Botox

, Reloxin

, Hylaform

, Juvederm

, and Captique

™

become part of the struggle to fi ght off wrinkles. Lasers and

light based therapies may be used to renovate the outer layers

of skin. This decade typically has a metabolic slowdown and

some people begin to seek liposuction of fat deposits that

were not even there ten years earlier. Smokers should give

serious consideration to stopping as doing so will reverse

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The Structure of the Skin & How This Changes with Aging

many of the bad changes in ones lungs and prevent a lot of

wrinkles as well.

40s—Serious skin maintenance begins in earnest in the 40s.

Accumulated damage is now apparent in the mirror and

under the microscope. Fine lines around the mouth and

eyes are an early hallmark of this period. Fortunately, these

are easily treated. Loss of subcutaneous elasticity causes the

smile lines to become prominent, and the entire face begins

to descend. Hormonal changes associated with menopause

begin to cause breakouts in women. Menopause may also be

the cause of breakouts for men living with women at this

point in life. Medications used to treat high blood pressure,

diabetes, and increased cholesterol may cause your skin

to develop various types of skin problems including hair

loss, hyperpigmentation, bruising, rashes, and sensitivity to

the sun.

Skin cancers begin to appear in fair skinned people as

they enter their third and especially their fourth decades.

Dermatologic care is now at least an annual affair (usually

more likely to be at six month intervals). Treatments men-

tioned during the 30s are used in greater combinations and

quantities. Soft tissue augmentation of smile lines and cor-

ners of the mouth in addition to botulinum toxin treatments

for frown lines, neck bands, and crow’s feet are routine

treatments for my patients in their 40s. Volume replacement

becomes a consideration, and volumizers (products that

create volume rather than replace it) such as Sculptra

are

helpful. Brown spots and capillaries of the face, which result

from accumulated sun damage, hormones, and genetics may

be safely and effectively treated with lasers, intense pulsed

lights, and topical medications and cosmeceuticals.

50s and 60s—The epic struggle begins. If you have wor-

shipped at the altars of good skincare and prevention and

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have a good rapport with your cosmetic dermatologist, you

will be well positioned to look and feel great at this point in

life. Embrace the 50s and 60s with visits to the dermatologist

three to four times per year instead of two. Whereas prior

appointments may have required one syringe of fi ller and 25

units of Botox

, two to three times that amount will now

be required. To provide the best surface appearance as well

as optimum tone and texture, Retin-A

or Avage

combined

with green tea and exfoliation should be part of your daily

regimen. Fortunately, the available options increase every

year as the technology continuously improves.

“Patients in their 50s and 60s are frequently the most fun

for a cosmetic dermatologist to care for because we can

make a huge impact.”

If you have not taken care of your skin, or if you have

been a sun worshipper or smoker or simply have bad genes,

you may require more than fi llers and Botox

. In this case, a

facelift with ablative laser resurfacing may be needed.

Changes seen on the surface of the skin during the 50s

and 60s correspond with signifi cant changes seen under

the microscope. Oil glands begin to lose their function and

the skin becomes drier. The collagen and elastic fi bers have

become ragged and thin. Epithelial cells damaged by years

of sun become disorganized and form small scaly bumps on

the ears, nose, and lips. These actinic keratoses—precancer-

ous growths that may progress if they are not treated—are

common in sun damaged skin. Put simply, people that spent

a great deal of time in the sun will age faster than those

who did not. Menopause causes changes in the skin that

mirror the hot fl ashes and night sweats of the rest of the

body. Decreasing estrogen levels are associated with skin

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The Structure of the Skin & How This Changes with Aging

that becomes thinner and dryer. Rational skincare must take

these changes into account. In addition to these changes,

conditions such as rosacea and seborrheic dermatitis

become more noticeable. Supplemental hormones includ-

ing testosterone may cause abnormal hair growth and acne.

With all of these changes, it is common to require a change

in your skincare regimen. This may include the addition of

prescription medications and the use of products that are

milder and more emollient. Medications prescribed for non-

dermatologic conditions are used with increasing frequency

and these may cause side effects including hyperpigmenta-

tion, hair loss, and rashes.

Volume replacement with fat transfers, Sculptra

, col-

lagen, hyaluronic acids, and Radiesse

™

permit restoration

of a more youthful appearance. Chemical peels will rejuve-

nate the outer layers of skin. Lasers and radiofrequency can

tighten collagen and elastic fi bers. Botulinum toxin treat-

ments with Botox

and Reloxin

previously confi ned to

frown lines and crow’s feet are used to treat the neck, lips,

and chin.

Palm Beach Peel

products were designed for skin

rejuvenation. Green tea, retinol, growth factors, vitamin C,

and glycolic acids provide the skin with the nutrients

and antioxidants required to help turn back the hands

of time.

“If Emeril were a dermatologist, this is when he would ‘Kick

it up a notch!’”

70s and beyond– During these years, surgical intervention

in the form of a facelift may be required to remove excess

skin and reposition a sagging face. Treatments used during

the 50s and 60s are utilized with increasing frequency and

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greater volumes. This may include Botox

, fi llers, lasers,

intense pulsed lights, and chemical peels. Skincare regi-

mens that previously consisted of one or two products may

require twice that many.

In the following chapters, we will examine both topical

treatments, prescription therapies, as well as the most

advanced options for rejuvenation on the market today.

PALM BEACH PERFECT SKIN

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CHAPTER

The Sun &
Your Skin

“Start wearing a broad spectrum

sunscreen everyday and your face

will love you forever.”

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PALM BEACH PERFECT SKIN

The leading cause of preventable skin damage is ultravio-

let radiation. Since we can prevent and sometimes treat

this damage we will begin with a discussion of the effects

of the sun on skin and proceed with a discussion of treat-

ment. Common sense dictates that two people with differ-

ent types of skin will have different results from the same

degree of sun exposure. Fair skinned, blue eyed people

(Fitzpatrick Skin Type 1) have skin that evolved to live in

England, Ireland, Scandinavia, and places without signifi -

cant ultraviolet exposure. Darker skin with more melanin

(Fitzpatrick Type 6) is better adapted to sun exposure and

designed for tropical latitudes. These differences in pigmen-

tation translate to requirements for high SPF for people

with fair skin and lower SPF for those with darker skin. The

requirement for differing degrees of protection depend-

ing on skin type is my main fault with skincare moistur-

izers that include SPF 15 and are marketed as “daily wear.”

They are not adequate for the daily activities of most of the

people who purchase them. For instance, skin that needs

SPF 50 will burn with only an SPF 15 on. My skincare prod-

ucts leave out sunscreen and require the user to choose

the sunscreen specifi c to their location, season, and type of

skin. This, I believe, ensures that they get the best protection

while enjoying the best products.

In order to understand why sun protection is necessary,

consider what ultraviolet light does to the skin. Ultraviolet

light interacts with the skin by radiating it. Different types of

ultraviolet light penetrate to different levels and have inter-

actions with molecules and cells. One signifi cant interaction

is with the DNA of the skin. As DNA is affected by sunlight,

it is altered and the information contained in the DNA is

changed. Most of the time, the damage can be repaired but

as we get older our ability to repair DNA decreases and

mistakes begin to accumulate. As this occurs, faulty genetic

information is translated into defective proteins and abnor-

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malities in the cells are seen. Abnormalities including skin

cancer may result from the damage. Ultraviolet radiation

also damages collagen and this is seen on the surface as

wrinkles. Liver spots are also seen following exposure to

sunlight as the body tries to shield itself.

However, the sun is not entirely without benefi t. Its role

in the production of vitamin D as well as producing a gen-

eralized feeling of well being has been known to dermatolo-

gists for years. How then to reconcile these two confl icting

facts? For me, the answer is simple: moderation. Specifi cally,

I believe it is important to avoid sunburns because they

infl ict signifi cant damage in a short time. Since the num-

ber of blistering sunburns correlates with the incidence

of melanoma, it is reasonable to do everything possible

to avoid blistering sunburns for you and your family. Early

sun damage has the most impact on the skin so teach your

children about sun protection and use adequate sun block,

sunscreen, or sun protective clothing to avoid early skin

damage. Although early damage is the most important, later

ultraviolet exposure also impacts the skin. Prudent sun pro-

tection throughout ones life will help to avoid wrinkles and

cancers. I advise my patients not to become hermits (which

some in my profession would advocate) and to enjoy

themselves but also to be cautious and avoid sunburns and

prolonged sun exposures at all costs.

One question frequently asked by patients in their 60s

and 70s is whether they can have any sun exposure. Usu-

ally, these patients want to participate in water sports, golf,

or tennis but are worried about skin cancer and wrinkles.

I believe that since the risk for wrinkles and skin cancer

has largely been determined by sun exposure prior to the

age of 60, the benefi ts of exercising in the sun (including

decreased rates of depression and osteoporosis) outweigh

the risks at that age.

I have found that many of my skin cancer patients, par-

The Sun & Your Skin

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PALM BEACH PERFECT SKIN

ticularly those with basal and squamous cell carcinomas, also

have macular degeneration. This makes some sense since

the same ultraviolet light responsible for damaging the skin

also damages the retina. In order to protect against macular

degeneration, I recommend that adults and children wear

polarized sunglasses (think of them as an SPF 30 for your

eyes).

Preventing Sun Damage

“The best way to deal with wrinkles is avoidance.”

Preventing sun damage is an important aspect of any skin-

care program. Although prevention is particularly important

when we are young, it plays a part in skin wellness at every

age. Using SPF 30 when you are 20 is going to trump using

SPF 100 when you are 60, so do everything in your power to

avoid sunburns while you are young, and protect your chil-

dren while they are too young to protect themselves.

Sun protection is an evolving concept. One great discus-

sion of photoprotection (protection from the sun) was writ-

ten by Kullavanijaya and Lim

. They explain that sunlight

consists of different components. These include UVA, UVB,

and UVC. UVA is the radiation that penetrates deeply but

does not produce sunburns. It is the ultraviolet light used

by tanning booths to induce the production of melanin.

UVB causes sunburns and is responsible for a fair amount of

damage seen as wrinkles, liver spots, and thinned skin with

bruises (due to damage to the connective tissue). UVC is

fi ltered by the ozone in the atmosphere, and it typically does

not affect our skin. Recent holes in the ozone layer are now

allowing the dangerous UVC rays to reach the earth’s surface

with consequences that will not be known for years.

Kullavanijaya, P Lim, H JAAD 2005;52:937-58

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The concept of sun protection has evolved with our

understanding of how ultraviolet light interacts with the

skin. The leader in this area is Australia. With their fair-

skinned population and love of outdoor activities, they

have become the leaders in many skin cancer treatments.

Recently, they have developed the concept of “UV Protection

Factor” which is meant to be analogous to SPF.

The concept of “SPF” is one frequently used by physi-

cians, manufacturers and consumers when deciding which

sunscreen to use. Unfortunately, this concept only measures

protection from UVB and was originally designed as a means

of avoiding sunburns. SPF has no relevance to UVA—the

deeply penetrating radiation.

Ultraviolet Protection Factor (UPF), on the other hand,

refers to the amount of total ultraviolet fi ltration a type of

clothing provides. This is a much better and more rational

scale to use when considering skin protection factors. If you

have any doubts about why UVA should be considered, take

a look at the 40-year-olds who have been to the tanning beds

and been regularly exposed to UVA—they tend to “hit the

wall” early and look 20 years older than people who have

never used tanning booths. For those who have any linger-

ing doubts about whether behavior infl uences skin health

and appearance, take a look at the people that not only go

to tanning beds but also smoke—they look twice their age.

These patients are the most diffi cult to treat because there is

not enough Botox

, fi llers, or peels to reverse the profound

damage that has been done.

When considering which sun protection product to use,

remember that SPF applies only to UVB and look for products

that have UVA protection as well. Unfortunately, there is no

agreed upon UVA rating scale and one may need to resort

to trial and error. Products that have micronized titanium or

zinc dioxide (known as sun blocks or “sensitive skin” prod-

The Sun & Your Skin

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PALM BEACH PERFECT SKIN

ucts) have particles that provide physical barriers, and they

are good at blocking both UVA and UVB. When selecting

sunscreens, I try to use products that offer UVB protection of

at least 45 and usually higher (as measured by SPF) and that

contain a UVA protection ingredient such as Parsol

1789,

zinc, or titanium dioxides or Mexoryl

—which although not

approved in the United States is a great product. I also like and

recommend protective clothing sold by Radicool, Solumbra

and Columbia. Ignoring, sun protection produces conse-

quences that depend on ones exposure history, genetics, and

environment. Given the same degree of sun exposure, light

skinned people who do not protect themselves will begin to

see signs of premature aging at earlier ages. Wrinkles and thin

skin will begin in the late 20s instead of the mid-30s. At about

the same time, small scaly lesions will begin to appear on the

ears, lips, nose as well as on the hands and arms. These actinic

keratoses, are the warning signs that signifi cant damage has

resulted in cancerous cells. The topic of skin cancer and

actinic keratoses is discussed more in later chapters.

Sun protection produces no immediate results but is still

an essential part of any good skin wellness and anti-aging

program.

“When is comes to sun protection, more is better.”

Sun Protection Factors

What does high SPF really mean?

Sunscreens are labeled with SPF numbers meant to serve

as a guide to the protection offered by the contents within.

SPF ratings are calculated by comparing the time needed to

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produce a burn on skin covered with a given sunscreen com-

pared to unprotected skin. A sunscreen with an SPF 15 would

allow skin that would develop a sunburn in fi ve minutes to

burn in 75 minutes instead. Despite what your neighbors or

relatives (notoriously poor sources of dermatology research)

tell you, there are differences between 15, 30, and 60 SPFs. SPF

15 provides 93 percent absorption of UVB, while SPF 30 may

absorb 97 percent of the sun’s rays. SPF 50 takes the protec-

tion up to 98 percent. Many of my patients select an SPF 60

to minimize the damage from ultraviolet radiation, and I agree

with this approach. Even if the difference is only a few per-

cent of protection, more is defi nitely better. It is also impor-

tant to consider UVA protection when selecting a product;

and one containing Mexoryl

, Parsol

1789 or titanium/zinc

dioxide will afford you the best protection for UVA. Differ-

ent products are better for different seasons and different

activities so do not stay married to one tube or bottle. You will

need a different product when fi shing in Florida in July than

when you are walking your dog in New York in October. I use

SPF 50 on my own children. Many dermatologists use this in

conjunction with sun-protective clothing for themselves and

their families.

Choosing the correct sunscreen will not help if you

do not use the product correctly. Studies have shown that

most people do not apply adequate amounts of sunscreen.

The average person requires approximately one shot glass

of product to cover them. Another pitfall with sunscreen

use is not applying it frequently enough. Many products are

designed for about four hours of ultraviolet exposure. Others

(such as Neutrogena Sport) are designed for longer expo-

sures. The daily wear products with SPF 15 are not designed

for lasting protection, and people who rely on them for

protection will get burned. Products designed for water

resistance are essential when you plan to swim or sweat. A

product that is not water resistant will wash off at the beach,

The Sun & Your Skin

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PALM BEACH PERFECT SKIN

pool, or sporting event leaving you and your family without

any signifi cant sunscreen. Despite old wives’ tales to the con-

trary, water provides very little sun protection. Thus, swim-

ming requires the use of waterproof sun protection. Many

of my skin cancer patients have skin cancers on their lower

legs as a result of sunlight that refl ected off sand and water

during younger years spent at the beach.

Sunscreens (which absorb the sun) must be applied at

least 30 minutes before going outside so they have time to

become activated. This is in contrast with sun blocks which

function as physical barriers to the sun and work instantly.

Sun protection hints: Avoid the sun between 10 a.m. and 4

p.m., as these are the peak hours for harmful UV rays. Wear

protective clothing, such as a “French Legionnaire” hat with

a large brim and neck and ear coverage to spare your skin.

One fi nal word about sun protection: fi nd a product that

you do not hate. You may never love to use sunscreen or

sun block but with so many products available, you should

at least be able to live with one. Try gels, sticks, creams, and

foams until you fi nd one that works well for you. Several

great sun protection products are available on my website

(www.idealskin.com), and I change my offerings based on

the technology available and what my patients want.

Selecting an SPF

To help fi gure out which SPF to use, log onto the Weather

Channel’s website www.weather.com each morning and

look at the health section. I helped develop this service to

provide information about sun hazards in any location, on

any day. The site will suggest an SPF based on your skin type

and the weather for your location.

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SUN PROTECTION CHECKLIST

• Cover up with clothing, including a broad-brimmed hat, long

pants, a long-sleeved shirt, and UV-blocking sunglasses

• Avoid tanning parlors and all artifi cial tanning devices

• Examine your skin from head to toe once a month. If you

notice a change, see a dermatologist

• Have an annual skin examination by a dermatologist board

certifi ed by The American Board of Dermatology

• When outdoors, apply SPF 30 or higher liberally, uniformly,

and frequently

• Avoid unnecessary sun exposure, especially between

10:00 a.m. and 4:00 p.m

• Teach your children good sun protection habits at an early

age; the damage that leads to adult skin cancers and wrinkles
begins in childhood

• Sunscreens may be used on babies over the age of six

months (I use chemical-free on my own children)

• Year-round sun protection is vital—especially on vacations

to the beach or skiing where sun exposure is intermittent
and intense

• UV radiation can penetrate many types of clothing—one good

rule of thumb is to hold clothing up to a bare light bulb. If you
can see your hand, it is less than SPF 15 equivalent. I recom-
mend sun protective clothing and hats for children. Many
great products are now available from Solumbra or Radicool
who make great “French Legionnaire” hats that cover the
back of the neck and ears

• UV radiation penetrates automobile and residential windows

so if you are fair skinned, have children, or live in a high sun
exposure environment, you need to have your windows tinted

• UV radiation can damage your eyes, contributing to cataracts,

macular degeneration, and eyelid cancers

• Snow or ice refl ect UV radiation, which damage the face and

eyes at twice the normal rate

The Sun & Your Skin

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PALM BEACH PERFECT SKIN

• Sun protection is important for all skin types; the amount of

sun protection depends on your skin type, where you live and
the season you are in. Your dermatologist can provide some
guidance for you as to what would be reasonable for your
situation. In my practice, my patients use a lot of SPF 60
(La Roche Posay Anthelios) and Palm Beach

Esthetic

Sunscreens with SPF of at least 15 for basic protection
year-round

What to Do If You Get Burned

It happens to the best of us. In an effort to spend time with

our family or get some exercise, we go outdoors without

adequate sun protection. If this happens to you, take an over-

the-counter anti-infl ammatory such as aspirin or ibuprofen to

minimize the redness and infl ammation. Blistered skin may

be indicative of a second-degree burn and this requires medi-

cal attention. Over-the-counter hydrocortisone creams may

help soothe the skin and decrease swelling. A severe burn, or

one accompanied by fever requires immediate medical atten-

tion, as these conditions may be associated with heatstroke.

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CHAPTER

Skin
Maintenance &
Improvement:

Damage Control &
Repair

“This is the dawn of a new day in

cosmetic dermatology when we

have the ability to make visible and

meaningful changes to the skin with

topical treatments.”

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PALM BEACH PERFECT SKIN

A great deal of my professional life is spent discussing

creams, injections, lasers, and other techniques to reverse the

signs of aging. This chapter is an overview of some areas that

will be important for years to come. Included in this discus-

sion are prescription anti-aging creams, glycolic acid prod-

ucts, vitamin C products, green tea products, growth factors,

and other topical ingredients with signifi cant promise.

Advancements in
Cosmeceutical Skincare

The cosmeceutical market consists of products designed to

improve appearance. Traditionally, this was the province of

prescription medications, but new ingredients have made some

great products available to mass consumers. Cosmeceuticals

have grown exponentially over the past few years, and this

trend is expected to continue. They are the fastest-growing seg-

ment of the multi-billion dollar per year personal care industry.

For the mass consumer, new products are rapidly appear-

ing that contain the same high-end technology previously

reserved for elite prestige brands. This has resulted in a fl ood

of new products on the market and a new, large group of con-

sumers who has access and interest in them.

When considering any new product, trust your instincts.

Before purchasing a skincare product, learn about it and the

company selling it. Decide if it makes sense to invest in the

product based on the company’s track record in skincare

and the ingredients they are using. This section will serve as

a reference for skincare products but it is helpful to consult

your dermatologist for specifi c questions about your indi-

vidual skincare needs.

Moisturizers

Many skincare regimens will occasionally dry out the skin.

For this reason, it is important to use a moisturizer that does

not irritate your skin. Suggestions include: Theraplex Hydro-

lotion, Palm Beach Peel

Antioxidant Moisturizing Formula,

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Eucerin, Neutrogena, SkinMedica, and Clinique. You should be

able to fi nd something you like among the products available.

When considering several products, understand some basic

differences between them. The most basic difference among

moisturizers is whether it is an ointment, lotion, cream, or oil.

Ointments are the thickest and greasiest. They are used to pro-

vide the greatest moisture and the strongest barrier protection.

While they might be appropriate for the hands and feet, they

would not be great for the face. Creams are lighter than oint-

ments but heavier than lotions. They seal in moisture and may

be used on most parts of the body, including the face. Lotions

are thinner and lighter than creams. Absorbed rapidly, they tend

to be the most commonly used products because they are sim-

ple to apply and easy to spread. Oils are easily absorbed when

applied to damp skin but are less moisturizing than ointments,

creams, or lotions. They are great to apply after bathing.

Cosmeceutical Creams

Creams promising eternal youth have been around since

Cleopatra. At that time these creams used fermentation

to produce glycolic acids to treat wrinkles. Some present

day products still use glycolic acid, but many more utilize

molecules developed specifi cally to fi ght wrinkles. In this

section, we will consider some ingredients and products that

might be worth a try.

Prescription creams, including Retin-A

and Avage

should be part of any skincare program. Both are retinoids

derived from vitamin A (also known as retinol). They cause

the epidermis to remodel and rejuvenate. Following sev-

eral months of use, the underlying dermis becomes more

youthful and organized. Changes seen under the microscope

refl ect changes seen in the mirror.

Over-the-counter products that should be considered

include those containing antioxidants, vitamins, growth

factors, and other biologically active ingredients. Included

in this list are green tea (my favorite), licorice (a naturally

Skin Maintenance & Improvement

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PALM BEACH PERFECT SKIN

occurring steroid), glycolic acids, and epidermal growth

factors. Newer ingredients such as idebenone (found in

Prevage

™

) are antioxidants now marketed to the mass

consumer.

Glycolic Acid

Glycolic acids are usually derived from fruits or plants.

Results obtained from glycolic acid products depend on the

strength of the acid, the duration of contact with the skin,

and the type of acid used. These products can remove layers

of skin and the depth of penetration depends on the con-

centration of acid. Glycolic acids improve the appearance

of fi ne lines and wrinkles by causing some mild swelling of

the dermis. At lower concentrations (less than 20%), mild

exfoliation occurs in the outer epidermal layers. This concen-

tration is typically found in products sold at drug stores and

salons. Peels offered in dermatology offi ces use an increased

concentration of acid, and may produce peels that extend

into the upper- and mid-dermis. Day spa peels are usually in

between the concentrations available in over-the-counter

products and peels offered by dermatologists. They may be

strong enough to cause burns, particularly when the “medi-

cal director” has no training in dermatology. Several people

have been permanently scarred by these types of peels

performed in a spa environment.

When selecting a glycolic acid for home use, it is important

to determine the concentration of acid in the product as well

as its pH (which has an effect on the concentration of acid).

Glycolic acids come in washes (which tend to be mild), lotions

and creams (which may be stronger), and pads (which can peel

the skin and produce great results when used correctly).

Vitamin C

More than a decade ago, vitamin C products became the fi rst

“primetime” cosmeceutical. Developed at the Duke University

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Department of Dermatology, they quickly became commer-

cial successes. Clinical research demonstrated that vitamin C

stimulates collagen growth and provides some sun protection.

Incorporating vitamin C into skincare made perfect sense in

retrospect since it had been known for decades to be impor-

tant for collagen production. Vitamin C remains an essential

ingredient in many skincare products to this day.

Growth Factors

Growth factors hold a great deal of potential for skin rejuve-

nation. These compounds attempt to stimulate skin cells to

grow and replenish support structures (including collagen)

to a more youthful state. One early product from Skinmedica

includes epidermal growth factor, which stimulates epider-

mal cells to grow. More recent products including those

made by Neocutis* contain more growth factors, and they

are specifi cally targeting epidermal rejuvenation with their

technology. In theory this will produce new, undamaged

cells that can replace dead or damaged cells. A fair amount

of scientifi c research went into these products, and patients

who have tried them are generally happy with the results.

Newer products have increased concentrations of growth

factors and molecules that directly stimulate cellular growth.

Products on the horizon will likely contain ingredients to

prevent chromosomal endcaps (known as telomeres) from

unraveling. Overall, this is an exciting time to be involved in

cosmeceutical research.

Antioxidants

Antioxidants fi ght many effects of harmful free radicals that

damage DNA and result in aging. Although green tea has

been part of Eastern medicine for centuries, this rich source

of antioxidants has only recently been incorporated into

Western medicine and skincare. According to one recent

Skin Maintenance & Improvement

* Disclosure: I serve on the scientifi c advisory board for Neocutis

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PALM BEACH PERFECT SKIN

review, multiple ingredients found in green tea inhibit

the formation of skin cancers. These ingredients also have

anti-infl ammatory and anti-aging effects on the skin as well.

Unlike black tea, green tea is not fermented and this key

difference results in high levels of antioxidant polyphenols

contained in green tea. Made from the dried leaves of the

camellia sinensis plant, green tea, black tea, and oolong tea

are simply processed differently. Populations that consume

large amounts of green tea have a lower than expected

incidence of oral, bladder, prostate, and colon cancers. Ingre-

dients from green tea reduce damage caused by sunburns

when applied to the skin in a topical form. They hold prom-

ise as topical anti-cancer drugs and can cause apoptosis (pro-

grammed cell death) of malignant skin cells. These numerous

benefi cial effects of green tea are the reason that I have

included it into many of my Palm Beach Peel

products.

My patients love these products because of their anti-aging

qualities as well as the calming effects the products have

on the skin. People using these products have reported an

improvement of skin problems, including rosacea and mild

dermatitis.

The Palm Beach Peel

System

The Palm Beach Peel

System is to cosmetic dermatology

what teeth bleaching strips are to cosmetic dentistry. Before

the advent of whitening strips, you had to spend consider-

able time and money in the dentist’s chair to get whiter

teeth. Everything from expensive bleaching trays to high-

tech lasers were utilized in the pursuit of perfect teeth, but

all this changed with the arrival of home bleaching kits. As

a result, brighter and whiter teeth—once available only to

those who had the time and money to see a cosmetic den-

tist—are now available to everyone.

My goal with my skincare products is to make profes-

sional skincare available to anyone who wants healthier and

more beautiful looking skin. While there is no substitute for

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a visit with a professional dermatologist, the comprehensive

Palm Beach Peel

Skincare System can help you reach your

skincare goals.

Developed using my years of experience and training, the

Palm Beach Peel

Skincare System delivers innovative formu-

lations containing the highest quality ingredients designed to

exfoliate, nourish, and moisturize your skin

The Palm Beach Peel

Steps:

Exfoliation, Nourishment, Cleansing,

Moisturizing & Exfoliation

Exfoliation of the outer dead skin cell layer is either minor

or major with selected Palm Beach Peel

products. Minor

exfoliation is obtained with easy to use Palm Beach Peel

Exfoliation Pads. These pads have strengths of glycolic acid

ranging from 10% to 20%, combined with witch hazel to

tone the skin. At the higher glycolic acid percentages, these

unique pads are comparable to peels obtained in a spa or

salon. I recommend starting with the Palm Beach Peel

Exfoliation 10% pads unless your skin is extremely oily. These

pads should be used either once or twice daily depending

upon the oiliness and sensitivity of your skin. After using

one strength for about a month, you can then move up to

the next higher strength.

Major exfoliation is obtained with the Palm Beach Peel

Home Dermabrasion Formula. This contains self-heating

crystals for professional strength microdermabrasion. The

crystals, made from micronized bamboo, gently but thor-

oughly remove dirt, oil, dead skin cells, and surface debris

that can clog the pores. Since these crystals provide signifi -

cant exfoliation, they should only be used once or twice a

week and they should not be used on the same day as the

Palm Beach Peel

Exfoliation pads. Self-tanning products

will look better and last longer when applied after the Home

Dermabrasion Formula.

Skin Maintenance & Improvement

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PALM BEACH PERFECT SKIN

Skin Nourishment

Skin nourishment is a critical component of any effective

skincare regimen. The Palm Beach Peel

System has several

products designed to provide different types of nourishment

to the skin. Each is designed with a different key ingredient

for a different type of skin. My products include Eye Rescue

Formula, Retinol Recovery Serum, Antioxidant Rescue Serum,

and Growth Factor Serum. After reading about the products,

you should be able to select a skincare program that will help

you obtain skin that looks and feels great.

The Palm Beach Peel

Eye Rescue Formula was created

especially for the delicate skin under the eyes. This thin skin

is one of the most frequent sources for patient consultations,

and the Eye Rescue Formula addresses many of the issues

unique to this area. Eye Rescue Formula contains hyaluronic

acid to hydrate and plump the skin. Also found within this

serum are green tea and vitamins to nourish the skin. This

serum should be used twice a day (morning and evening)

but may be applied more frequently when traveling or in a

dry environment.

The Palm Beach Peel

Retinol Recovery Serum contains

retinol, hyaluronic acid, and green tea. Retinol is the vitamin

A derivative that is the precursor to Retin-A

. These ingre-

dients help to minimize the appearance of fi ne lines and

wrinkles and improve skin tone and texture. I have included

three strengths of retinol (0.2%, 0.3% and 0.5%). Begin with

the 0.2% and increase concentration after about four weeks.

If you experience skin irritation, decrease the usage to every

other night for about three weeks.

The Palm Beach Peel

Green Tea Rescue Serum com-

bines the hydrating qualities of hyaluronic acid with the

antioxidant benefi ts of green tea and caffeine. Although this

mix of ingredients may sound like something to order at

Starbucks, it has signifi cant levels of antioxidants that help

neutralize free radical damage to the skin. This product is

the cornerstone for any skin nutrition program.

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Apply the Antioxidant Rescue Serum after cleansing your

skin (or at least twice per day). A small amount (about the

size of a pea) is all that is required for the average face or

neck. The Palm Beach Peel

Antioxidant Rescue Serum has

a dark color due to its high antioxidant content. Rather than

add a coloring agent to make it look more attractive, I chose

not to dye the product.

The Palm Beach Peel

Growth Factor Serum contains

the human growth factor TGF-beta1 which stimulates col-

lagen production. Growth Factor Serum should be used on

skin that shows signs of moderate to severe aging. It should

be applied each evening, when the skin repairs itself. Palm

Beach Peel® Growth Factor Serum is available in concentra-

tions of 10% or 15%. Begin with the lower concentration for

about one month and then increase the concentration to

maximize your results.

Cleanser—My soap free Palm Beach Peel

cleanser is an

alternative to the harsh, drying soaps that are part of most

skincare systems. This unique product gently cleanses and

moisturizes the skin while delivering green tea and Coen-

zyme Q 10 to help nourish the skin.

Instructions for using the cleanser are simple. Apply a mod-

erate amount to moistened skin and gently massage the sur-

face with your fi ngertips or a soft washcloth. Gently dry your

skin with a soft towel and apply the antioxidant and moistur-

izer if your skin tends to be dry. Both of these products will

work better when applied to slightly moist skin. To maximize

skin hydration, do not allow your skin to dry completely

before applying moisturizers. It is much easier to seal moisture

into the skin than to replace it once it has been lost.

Note: If you are using a prescription acne product, let

your skin dry completely before applying this product.

If you do not, you greatly increase the risk of irritating

your skin.

Skin Maintenance & Improvement

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PALM BEACH PERFECT SKIN

Moisturizer—The Palm Beach Peel

Antioxidant Moistur-

izing Formula contains the natural emollients squalene and

glycerin which attract water to the skin and help soothe and

soften. The antioxidants vitamins A, C, E, green tea extract,

and CoQ10 are incorporated into this product so that your

skin gets the nutrition it needs.

AN OVERVIEW OF COSMECEUTICALS

Cosmeceutical

Indications

Effects

Other Forms

Retinoid
Precursors
& Derivatives

• Treat skin

disorders such
as acne, psoriasis,
and icthyosis

• Improve the

appearance
of aged and
photo-damaged
skin

• Reduce wrinkles

• Decrease laxity

• Bleach hyper-

pigmented spots

• Derivative of

vitamin A Retinol

• Carotenoids

Alpha/Beta
Hydroxy Acids

• Enhance

epidermal
shedding

• Improve quality

of elastic fi bers

• Increase collagen

density

• Reduce signs

of aging

• Smooth skin

• Can increase

sensitivity to
UV rays

• Alpha or Beta,

depending on
molecular
structure

• AHAs or fruit

acid including:
glycolic acid, lactic
acid, citric acid,
mandelic acid,
malic, acid and
tartaric acid

• BHA include

salicylic acid

Antioxidants

• Needed to

maintain the
equilibrium
between the
pro-oxidants,
or damaging
agents, and the
antioxidants, or
protective agents

• Normalize

changes caused
by photo damage

• Repair collagen

• Protect cell

membrane

• Normalize cell

turnover

• Vitamin C

(L-ascorbic acid)

• Vitamin E

• Panthenol

• Lipoic acid

• Ubiquinone

• Niacinamide

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Skin Maintenance & Improvement

Cosmeceutical

Indications

Effects

Other Forms

Antioxidants

• Intervene at

different levels
in the protective
process

• Speed up cell

growth, aid in
healing process

• Retard aging

process

• Dimethylamino-

ethanol

• Spin traps

• Melatonin

• Catalase

• Superoxide

dismutase

• Peroxidase

• Glucopyranosides

• Polyphenols

• Cysteine

• Allantoin

• Furfuryladenine

• Uric acid

• Glutathione

Depigmenting
Agents

• Remove excess

pigment, reduce
discoloration and
blotches, sun
damage

• Most effective

when the increase
of melanocytes
or melanin is
restricted to the
epidermis

• Can irritate the

skin

• Chemical peels

use a combination
of these agents
to remove excess
layers of the skin
or excess pigment

• Hydroquinone

• N-acetyl-4-S-

cysteanimylphenol

• Vitamin C

• Kojic acid

• Arbutin

• Azaleic acid

• Paper-mulberry

compound

• Tretinoin

• Chemical peeling

agents

• Chemical

compounds

Botanicals

• Use ingredients that

occur naturally for
the same purposes
as other cosmeceu-
ticals

• Soothe skin

• Protect cells

• Stimulate lipids

• Chamomile

• Avocado

• Aloe vera

• Ginkgo biloba

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PALM BEACH PERFECT SKIN

Cosmeceutical

Indications

Effects

Other Forms

Glycosamino-
glycans

• Decreased

amounts are
present in aged
skin so when
topically applied,
it replenishes lost
supply

• Stimulate wound

repair

• Rejuvenate skin

• Hyaluronic Acid

Enzymes

• Chemically digest

inter-cellular bonds

• Exfoliate keratotic

skin

• Repair sun

damaged skin

• Papain

• Deoxyribonucleic

acid

Growth Factors

• Stimulate cell

growth and repair

• Treat burns and

wounds

• Epidermal

growth

• Transforming

growth factor

Hormones

• Claim to reverse

the skin’s loss of
tone and elasticity;
not proven

• Claim to heal

skin conditions,
such as: acne,
psoriasis, rosacea,
seborrhea, and
keratoses; not
proven

• Estrogens

• Progesterone

• Testosterone

• Growth hormone

Peptides

• Stimulate collagen

and elastin
production

• Reduce appear-

ance of fi ne lines
and wrinkles

• Microcollagen

pentapeptides

• Copper peptides

Antimicrobial
Agents

• Fight bacteria as-

sociated with skin
conditions

• Clear up skin

• Triclosan

• Chlorhexidine

• Povidone iodine

• PCMX

(para-chloro-
meta-xylenol)

• Hydrogen peroxide

• Antidandruff

preparations

• Zinc pyrithione

• Deodorants

• Other antimicrobial

preparations

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Skin Maintenance & Improvement

Cosmeceutical

Indications

Effects

Other Forms

Topical
Anesthetics
& Antipruritics

• Relieve local

discomfort and
reduce pruritis
(itching)

• Help reduce

sunburn and acne

• Ethyl

aminobenzoate

• Benzyl alcohol

• Diperodon

hydrochloride

• Pramoxine

hydrochloride

• Menthol

• Capsaicin

Hair Removal
Agents

• Disrupt bonds

of hair keratin,
causing the hair
to break in half
and allowing it to
separate from the
skin

• Block the enzymes

or hormones that
stimulate hair
growth

• Depilatory agents

• Efl ornithine HCl

13.9% cream

• Ketoconazole

• Spironolactone,

fl utamide and
cyproterone
acetate

Hair Loss
Treatments

• Bind to receptors,

preventing the
binding of natural
androgens to
receptors

• Increase the

diameter of the
hair shaft

• Induce hair growth

• Promote cell

growth

• Create new hair

fi bers

• Spironolactone

• Cyproterone

acetate

• Flutamide

• Azelaic acid

• Ketoconazole

• Pinacidil, P-1075,

cromakalim, and
nicorandil

• Tretinoin

• FK 506-

tacrolimus

• Cysteine and

arginine

• Saw palmetto

(Serenoa repens)

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PALM BEACH PERFECT SKIN

Cosmeceutical

Indications

Effects

Other Forms

Scar
Management

• Silicone gel

sheeting

• Adhesive micro-

porous hypoaller-
genic paper tape

• Vitamin E

• Onion extract

cream

• Allantoin-sulfomu-

copolysaccharide
gel

• Glycosamino-

glycan gel

• Extracts of

Bulbine frutescens

• Extracts of

Centella asiatica

• Topical retinoic

acid

• Colchicine

• Systemic

antihistamines

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CHAPTER

A Lifetime of
Perfect Skin:

Why You Need a
Cosmetic Dermotologist

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PALM BEACH PERFECT SKIN

Perfect skin begins with the conscious decision to seek a

youthful, healthy appearance. It can be accomplished with

sensible living, advanced skincare, and the occasional visit

to a cosmetic dermatologist or plastic surgeon. Controlling

your diet, stress level, sleep (during which the body and the

skin repair themselves), sun exposure, smoking and alcohol

consumption will also help you get the best skin possible.

What Is a Cosmetic Dermatologist?

Cosmetic dermatology is the branch of medicine devoted

to optimizing the health and appearance of the skin. This

branch of dermatology is a division of dermatologic surgery,

the part of dermatology devoted to surgical treatments of

the skin. Cosmetic dermatologists use many techniques,

procedures, and products to enhance the appearance of the

skin. In this section I will discuss the various procedures and

products used by a cosmetic dermatologist.

Products used by cosmetic dermatologists are varied; some

represent cutting edge skincare while others are traditional

products designed to maintain healthy skin. When consider-

ing new products it is helpful to think about the research

behind them. Do not assume that more expensive products are

necessarily better than less expensive ones. Several extremely

expensive products are not signifi cantly different than others

that are available at less than half the price.

A complete skincare program combines in offi ce treat-

ments with products and procedures that are used at home.

The home-based portion of my program uses the Palm Beach

Peel

pads instead of some offi ce-based chemical peels.

The green tea serum, green tea cleansers and moisturizers

supplement prescription medications such as Retin-A

or Avage

A cosmetic dermatology consultation begins with a dis-

cussion of your particular goals and an examination of your

skin. Discussions of downtime associated with any potential

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procedures as well as any budgetary constraints should also

take place at the consultation. If your skin has good tone and

even color with minimal sun damage, resurfacing procedures

such as TCA (trichloroacetic acid) peels or lasers may not be

indicated. Frown lines, crow’s feet or forehead wrinkles can

be treated easily and thoroughly with injections of Botox

Myobloc

, or Reloxin

. Lasers, photodynamic therapy, or

intense pulse light devices might be utilized to restore a

more youthful appearance to the surface of the skin when

there has been a great deal of sun damage.

Wrinkles and folds due to loss of soft tissue are treated

with soft tissue augmentation. The material selected depends

on the goals, area to be treated, budget, and tolerance

for downtime. Superfi cial wrinkles may be treated with

Restylane

, Restylane

Fine Line, Juvederm

, Captique™,

Hylaform

, or a collagen product. Moderate lines might be

treated with Restylane

, Perlane

, Hylaform

Plus or Juve-

derm

. When loss of volume is the main problem, I might

recommend fat transfer, Perlane

, Sculptra

, or Sub Q. Using

combinations of treatments enables the cosmetic dermatolo-

gist to treat a variety of conditions, and make a great deal of

difference. In Palm Beach, perfect skin involves an integrated

approach to healthier and more youthful skin.

As with any medical procedure, it is important to remem-

ber that no two people and no two procedures performed

on the same person are exactly the same. It is impossible

to obtain perfect results with every patient or with every

procedure. If you begin a treatment program that does not

live up to your goals, you should discuss this with your

dermatologist. Sometimes a minor change in how a product

or procedure is used, or an enhancement procedure may

give you the results you desire. In some instances the goals

rather than the procedure must be adjusted to the reality of

a particular situation. One common scenario where goals

must be adjusted involves a patient with limited ability to

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undergo a procedure. For instance, he or she can only afford

one syringe of Restylane

or 25 units of Botox

and is then

not satisfi ed with the fact that they still have wrinkles. This

type of scenario may be minimized during your consultation.

Know Your Skin Type

The type of skin that you have has a great deal of impact on

the types of treatments and products that your skin needs.

Skin types can be categorized in a variety of methods. Two

that I fi nd helpful are the Fitzpatrick scale for “fairness” of

skin, and a scale that measures the amount of oiliness or dry-

ness of the skin.

If one type of skincare product were perfect for all skin

types, the cosmetics department of any retail store would

consist of one large, expensive bottle. Subtle differences

among different skin types make dermatology so fascinat-

ing and skincare products so complicated. Understanding

your particular skin type and its unique needs will help to

maintain ideal skin.

The Fitzpatrick grading scale is useful in describing

sensitivity to the sun. In general, people with low Fitzpat-

rick skin types (for example,Type 1 or 2) have different

skincare issues than darker skin types. The Fitzpatrick scale

breaks skin types into six basic categories. On one end of

the spectrum is a Type 1 skin. These people never tan and

always burn. They tend to have very sensitive skin, are prone

to rosacea, and require signifi cant sun protection in order

to maintain ideal skin. The other end of the spectrum is

identifi ed as a Type 6 skin type. This is typically an African-

American skin type that has a great degree of pigment. Sun

protection is less important here than it is in Type 1 or fair,

thin skin. In addition, this type of skin tends to age better

and have fewer problems than lighter toned skin. Toward

the middle of the scale are people with olive skin and dark

eyes who tan easily.

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FITZPATRICK CLASSIFICATION

Type Description

Very fair skin, I never tan, I burn

Light skin, I may tan, but I usually burn

III

Light to medium complexion, sometimes I tan,
sometimes I burn

Medium complexion, I usually tan, rarely burn

Dark complexion, I usually tan, rarely burn

Black complexion, I never burn

With respect to the degree of oil found in the skin, there

are four basic types of skin: normal, oily, dry, and combina-

tion. At the two extremes are oily skin and dry skin. Oily skin,

common in some Hispanic and Mediterranean skin types, has

a greater number of sebaceous glands than dry skin. Interest-

ingly, oily skin tends to have fewer wrinkles than dry skin of

the same age and sun exposure. Dry skin typically gets fl aky

and irritated especially in dry weather. It tends to be more

susceptible to sun damage and other environmental injuries.

Obviously, products designed for darker, oily skin are not

good for lighter, dry skin. For instance, oily skin does quite

well with products that contain salicylic acid but sensitive

skin does not tolerate this ingredient. These distinctions are

also a factor for a dermatologist prescribing medications

such as Retin-A

or topical antibiotics. The strength and

vehicle must take the skin type into consideration if the

product will be used on an ongoing basis.

Midway between the oily and dry extremes is normal

skin, the skin type shared by most people. Normal skin pro-

duces enough oil to retain moisture without appearing shiny

or greasy. Pores are medium sized and not prominent. This

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contrasts with pores found in oily skin types which tend to

be large and prominent. Salicylic acid products such as Palm

Beach Esthetic Acne Pads and Wash are helpful for oily skin

but would not be appropriate for dry skin. When selecting

a sunscreen, a gel based formulation may be appropriate for

oily skin. For an antioxidant, the Palm Beach Peel

Green Tea

Serum is appropriate for oily skin.

Dry skin requires gentle care and a well thought out

skincare program. Products and procedures that are fi ne for

normal skin will irritate dry skin. Topical drugs such as Retin-

that are used by many people without a problem will

cause dry skin to become red. Cleansers for dry skin must be

soap free and moisturizers should not contain high con-

centrations of glycolic acids or vitamin C (even mild acids

may not be tolerated). Bland emollients will help dry skin to

maintain its health.

Combination skin contains some areas that are oily and

others that are dry or normal. The “T-zone” adjacent to the

nose is the most frequent combination skin zone and this area

may require separate products than the surrounding skin.

In my practice, a typical skincare regimen looks like this:

DAY NIGHT

Cleanser (the type of cleanser used
depends on the condition of your
skin—astringent based for oily and
non-detergent based for dry)

Cleanser

Eye Cream

Toner (optional for oily skin)

Moisturizer Eye

Cream

SPF30 if you are planning to be
outside

Thicker moisturizer

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How to Choose an Ideal Skin Regimen

When selecting skincare products, choose products that you

can live with both emotionally and fi nancially. Select prod-

ucts that you can use month after month without feeling

that you need to mortgage your home. Also, choose prod-

ucts that can provide results in a time frame that is accept-

able to you.

Before You Buy

Answering a few simple questions about your skin will help

you choose the best products for you:

Identify your skin type—Is your skin predominantly oily,

dry, normal, sensitive, or some combination of these? Are you

light skinned with blue eyes or dark skinned with dark eyes?

(see The Fitzpatrick scale on page 63). Skin that is dry will

need products designed to retain moisture, while skin that is

oily requires products that are drying. This seemingly obvi-

ous statement of fact is frequently overlooked by consumers

and salespeople selling skincare products. Once you have

begun to understand your skin type, begin to defi ne your

goals.

Identify your skincare goals—Do you need a wellness

program that will forestall aging, or do you need a treatment

program for a specifi c problem such as acne, rosacea, or

hyperpigmentation? Defi ning the issues that are important to

you is half of the struggle for perfect skin.

Assess your lifestyle—If you smoke, have a poor diet, and

spend a lot of time in the sun and you are not willing to

change these behaviors, it will be diffi cult to have optimal

skin (or any other part of your body for that matter). If you

are too busy to apply moisturizer once a day, it is going to

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be diffi cult to transition to a program that utilizes fi ve or six

steps. Perhaps beginning with one or two products would

be a more realistic starting point. A sensible perspective on

the quest for perfect skin is as important as the products and

dermatologist you select. The best products will not do any

good if they sit on a shelf.

Adopt a regimen approach—When trying skin products,

remember that you should use a one month trial period to

allow for fl uctuations due to hormones (menstrual cycle for

women) and varying environmental conditions. Begin with

a combination of three or four products (cleanser, toner,

moisturizer, exfoliator, and/or eye cream). Add one new

product at a time to determine how it interacts with your

skin. This enables you to isolate a problem product if your

skin reacts poorly. Another reason to try products for a full

month is that the skin cycle takes about 28 days to get cells

from the bottom of the epidermal layer to the top of the

epidermal layer. Thus, a full cycle is needed in order to give

a new regimen a reasonable chance. Most of my patients use

our Palm Beach Peel

Home Exfoliation system with Green

Tea Cleanser and the Antioxidant Moisturizer. In addition,

many use the Eye Rescue Serum and the Retinol Recovery

or Growth Serum.

THE BASICS: Six Steps for Ideal Skin

1. Exfoliate using the Palm Beach Peel

2. Cleanse and/or tone using green tea cleanser

3. Apply medication for dermatologic issues (prescriptions may

be necessary)

4. Apply an antioxidant such as the Green Tea Serum

5. Apply a moisturizer

6. Protect from the elements with sun protection products

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1) Exfoliate—As discussed previously, the Palm Beach Peel

is the perfect way to remove debris from the skin. You can

control the extent of exfoliation by using this system more

or less frequently. As with any part of a good skincare regi-

men, the key here is moderation—do not scrub so hard that

your skin is raw. Other methods of exfoliation available at

the dermatologist’s offi ce may be used to augment the Palm

Beach Peel

. These include chemical peels and microderm-

abrasion. Products containing salicylic acid also exfoliate to

some degree, and these may be helpful for skin that is oily or

prone to acne.

2) Cleanse/Tone—In addition to the peel pads other

products are helpful for removing debris from the skin.

The green tea cleanser is one such product. Salicylic acid

washes may be helpful for oily or acne prone skin. The right

cleanser or toner is the one that works for you. There is no

perfect product that works for all skin types and all environ-

ments. Ask your dermatologist for suggestions based on his

or her experience.

3) Apply Medications—Skin conditions that require

prescription strength medications require additional care. If

your dermatologist is using topical medications to treat acne,

eczema, dark spots, precancerous growths, skin cancers, or

other skin conditions, you will need to apply this medica-

tion before application of other topical products and after

the skin has been cleansed. In the event of irritation or other

skin reaction, you should discontinue use of all products and

check with your doctor.

4) Apply Antioxidants—At the present time, green tea is

the richest source of antioxidants and should be used on

a regular basis. Other antioxidants such as vitamin C are

also important, and you may want to use them as well. As

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new ingredients are developed, they will be incorporated

into my skincare products.

5) Moisturize—The amount of moisture required by the

skin depends on the amount of oil it produces and how dry

the surrounding environment is. Having enough moisture in

the skin is vital to maintain an effective barrier and to ensure

the integrity of the skin. Some diseases impair the barrier

function and these impose increased moisturizing require-

ments. For the face, the Antioxidant Moisturizer will deliver

moisture deep into the skin and it contains antioxidants

as well. When considering moisturizers for the body, there

are many fi ne products available. These include Theraplex,

Eucerin, Cetaphil, and several others that can replace mois-

ture without causing skin irritation.

Different seasons and locations require different products

so do not be surprised if you need separate products for

the summer and the winter. Women may fi nd that they need

different moisturizers at different points in their hormonal

cycle. Further complicating skincare is the fact that differ-

ent parts of the face require different degrees of moisture

because they have different densities of oil glands. The

“T-zone” frequently requires drying agents, while the eyelid

area an inch away needs extra moisture. My suggestion is to

try a few products and then discuss your response to each

with your dermatologist during an appointment set up for a

cosmetic consultation.

6) Protect—All types of skin require protection but the

amount of protection depends on genetics as well as internal

and external conditions. Protection from the elements ranges

from sunscreen and sun block to moisturizers, exfoliating

peels, and medications with sun protection in them. A more

complete discussion of sun protection is in Chapter 2, so I

will summarize by stating that repairing damage without pro-

tection from further insults is a fruitless exercise.

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Doctor’s Advice: Do not try to cram in a cosmetic consulta-

tion during a routine skin cancer or eczema evaluation. You

will end up frustrating yourself as well as the physician.

Seasonal Skincare

Skincare needs to take into account not only your type of

skin but also where you live and the time of year. If you

are lucky enough to live in San Diego, which enjoys near

perfect temperature and humidity, skip this section. When I

lived in Chicago, I noticed that many conditions were much

worse during the cold, dry winter months and improved

during the summer. Many of my patients there needed dif-

ferent products as each season arrived. This made me think

about seasonal skincare. Thin moisturizers that were fi ne

in Florida were not suffi cient during winters in Chicago.

Products that were perfect in January were too thick for the

summer months.

One frequent problem in dry environments is a type of

dermatitis (known as xerotic dermatitis) characterized by

dry, cracking skin. Treatment for this required using topical

steroids and moisturizers. Other treatments such as Elidel

(Pimecrolimus) and Protopic

(Tacrolimus) may also be

helpful. Simple changes can also help your skin when living

in dry environments. A humidifi er will replenish moisture

when placed in the bedroom. Applying moisturizers to skin

that is slightly damp will help the skin retain moisture with

more effi ciency than simply applying products at random.

One myth that should be addressed is that drinking more

water will increase the moisture of your skin. No matter how

much you drink, you will not make a signifi cant difference in

your skin’s moisture content unless there happens to be a jar

of moisturizer in the bathroom.

As winter comes to an end, daylight and humidity

increase. As this occurs, it is a good idea to modify your

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skincare. You should do so every time you add or remove

an hour from your clock at daylight savings time. Increased

humidity during spring and summer means that thick mois-

turizers may be replaced by thinner products. As mold, trees,

and fl owers begin to come to life, allergies may fl are and

the skin may experience rashes not seen at other times of

the year. During the summer, sun protection is increasingly

important. Warmer months may also require astringent and

toners to help clear excess oils that may be produced during

the summer.

In summary, an ideal skincare regimen is different for

different types of skin, as well as at different points in life.

I recommend re-evaluating your skincare regimen annually

and consulting with your dermatologist when you need

assistance.

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CHAPTER

Maintaining
Clear Skin When
You Have Acne

“Most people are affected by acne

at some point in their lives. It is a

chronic condition that requires

consistent daily maintenance.”

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Over one billion dollars is spent every year on over-the-coun-

ter acne products with an estimated $600 million spent on

one product touted by telemarketers alone. To put this in per-

spective, there was only one segment of the skincare industry

that spent more than acne: the anti-wrinkle segment.

Understanding Acne

Acne is caused by three factors: bacteria, hormones, and

sebum (oil). Increased adhesion of the epidermal cells also

contributes to acne. Recently, some studies have demonstrated

that diet may play a role in acne, although the fi ndings are

preliminary and more work needs to be done in this area.

Not every pimple is acne, and an occasional breakout

should not prompt you to demand Accutane

from a derma-

tologist. Understanding the various types of acne and the

treatments for each will help you to take better care of your

skin. Conditions other than acne, including infections with

yeast and unusual bacteria, can produce pimples without

being acne. Rosacea can mimic acne, and even some dermatol-

ogists have diffi culty distinguishing between the two. Occupa-

tional exposures to chemicals can also lead to conditions that

stimulate acne. Only a dermatologist is trained to consider

these and a variety of other factors when evaluating your skin.

What is acne?

In its most simple form acne consists of blocked hair follicles,

which dermatologists call a comedone. Comedones come

in two varieties: open and closed. Closed comedones (white-

heads or “zits”) form when a follicle is blocked beneath the

surface of the skin. Debris such as oil and dead skin cells build

up under the plug. As the pore swells, breaches in the wall of

the follicle occur. Material leaks into the adjacent skin and the

body produces an infl ammatory response. From the outside

this appears as pus fi lled bumps.

Open comedones (blackheads) are follicles blocked by

dead skin cells and oil. In contrast with closed comedones,

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the surface of the follicle is open to the air. Dead skin cells

and other debris react with the air and gradually change color.

This oxidation produces chemicals that turn dark in much the

same way that an apple changes color when exposed to the

air. Contrary to popular belief, blackheads are not the result of

dirt. Scrubbing them in an effort to “clean” them will simply

irritate the skin or make the situation worse.

Acne may also have predominantly pustular or cystic sub

types. Pustular and cystic acne are notable for collections

of dead skin cells, bacteria, white blood cells, and oil. These

forms of acne may be helped by oral antibiotics, topical

antibiotics, IPL, PDT, hormone blockers, or Accutane

and its

generic equivalents.

Oral Acne Treatments

The most popular acne treatments are oral antibiotics, which

kill the p. acnes bacteria found in many acne lesions. P. acnes

lives in the skin where it metabolizes sebum (skin oil) to

form infl ammatory substances. Normal doses of antibiotics

have been used for decades in the treatment of acne and

they are known to be relatively safe and effective. New data

on smaller doses of antibiotics reveal that these doses may

also be effective. These low doses avoid many of the com-

mon side effects seen with traditional acne treatments.

The antibiotic with the longest history of acne treatment

is tetracycline. It has been used for decades and remains

popular among dermatologists to this day. It may be used for

months or years with minimal side effects. Lab tests should

be performed on a regular basis when long-term antibiotic

usage is prescribed by your dermatologist. In addition, preg-

nancy should be avoided when antibiotics (or most other

medications) are prescribed (especially tetracycline and sulfa

based products). Minocycline and doxycycline are derived

from tetracycline and are also effective for the treatment of

acne. Minocycline may cause blue-gray discoloration of the

skin and teeth, headaches, and dizziness. If this happens,

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PALM BEACH PERFECT SKIN

stop taking the drug immediately and notify your dermatolo-

gist. Doxycycline can increase the risk of sunburns, so use

caution if you are taking this drug and plan to be outside.

Oral erythromycin is one alternative to tetracycline that is

considered safe for pregnant women. Sulfa-based antibiotics

are used by some dermatologists, but I prefer to avoid them

in most cases due to the side effects (known as erythema

multiforme) that may rarely occur.

Accutane

and Its Generic Versions

Accutane

, a vitamin A derivative, is a cure for severe scar-

ring acne. Generic versions of Accutane

are available,

although I tend to use the original because of my experience

with this product and the extensive monitoring program

that Roche has developed.

Recent Congressional inquiries about Accutane

have

placed this drug in the regulatory cross hairs. Although I

tend to be conservative in my use of drugs, if my children

develop severe scarring acne, I will prescribe Accutane

for

them. My experience with this drug spans a decade, and I am

impressed with the transformation that I have seen in many

teens and young adults. Previously introverted people have

higher self esteem when they have a better appearance. If

you are considering using Accutane

, you must consider the

associated risks, and discuss them with your dermatologist

before beginning a course of therapy.

Accutane

works by decreasing oil in the skin, adhesion

of skin cells and bacteria in the follicle. It is the only drug

that effectively addresses these different steps in the produc-

tion of acne. We all know people with deep pockmarks and

scars from acne. These permanent scars become a part of the

person’s personality. Extensively scarred people may become

shy and sometimes even depressed. Fortunately, a variety of

dermatologic treatments are available such as laser, derm-

abrasion, surgery, and injections of Sculptra®, Restylane®,

and a variety of other fi llers.

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Depression is one of the major side effects associated

with acne. This can occur from time to time in any person,

but the incidence of depression in those who have severe

scarring acne is signifi cant. People on Accutane

who expe-

rience depression should consult their dermatologist and

psychiatrist immediately. If you have a history of depression

and are considering using Accutane

, you should talk to

your dermatologist and/or psychiatrist about whether this

treatment is appropriate for you.

It is imperative to avoid pregnancy while taking Accu-

tane

, which causes severe birth defects. Two forms of birth

control are recommended for any sexually active woman tak-

ing Accutane

. The long list of potential problems associated

with Accutane

, combined with advertisements by attorneys

who want to sue doctors, are the two major reasons that

physicians avoid prescribing it. This is a shame because Accu-

tane

can be a miracle drug in the right situation.

Hormonal Therapy

Hormones play a key role in the development of acne, and

manipulating these hormones can clear up acne. Medications

such as birth control pills can trick the body into making less

acne inducing male hormones, while other drugs may block

the male hormones from binding to their receptors. Dermatol-

ogists have known for years that excessive male hormones may

cause acne. Any parent can verify this during the teen years

when hormones and acne simultaneously fl are up. Recent

steroid scandals in professional sports have shown a curious

connection between steroid use and acne, which can be seen

on players at press conferences.

The diuretic spironolactone is a mild anti-androgen, and it

helps some women (especially those with polycystic ovary

disease) combat hormonal based acne. Some birth control

pills such as Ortho TriCyclen and Yasmin also fi ght acne, so

they are sometimes included in acne treatments.

Maintaining Clear Skin When You Have Acne

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Topical Acne Treatments:

Prescription,

Over-the-Counter Products, Light Based

Treatments and Daily Care for Acne Prone Skin

A prescription from a dermatologist

Prescription medications available for topical application

include retinoids, benzoyl peroxides, antibiotics, and various

combinations of all of the above. The retinoid family consists

of Retin-A®, Tazorac

(Allergan), and Differin

(Galderma).

These products normalize epidermal turnover, allowing

skin cells to slough off more easily. Retinoids may initially

cause the skin to appear worse as debris moves through the

follicle. Retinoids will also make your skin more sensitive to

chemical peels, waxing, microdermabrasion, and facials.

Topical antibiotics are available in a variety of formula-

tions including: gels, creams, foams, lotions, and solutions

so it should be easy to fi nd a product that is suited to your

skin type. Frequently used antibiotics include clindamycin,

erythromycin, and sulfa based compounds. Benzoyl peroxides

are available in prescription strengths as well as in over-the-

counter versions. These products have a long history of safety

and effi cacy. Like antibiotics, they are available in everything

from gels to creams and a variety of formulations in between.

Topical prescription medications have a signifi cant role in the

treatment of acne as they can frequently deliver antibiotics to

the hair follicle without systemic side effects.

Non-prescription options

There are many over-the-counter products available to treat

acne, and this industry is a large business. Over-the-counter

acne medications typically utilize salicylic acid, benzoyl

peroxide, or drying agents such as colloidal sulfur. Salicylic

acid is frequently used because it can gently unclog pores.

This product is available in a variety of formulations includ-

ing gels and washes, as well as in different concentrations.

The most common concentration is two percent. Palm Beach

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Esthetic Center acne products are medicated and contain

benzoyl peroxide or salicylic acid.

Light based treatments

These acne treatments use lasers and intense pulsed lights

(IPL) to destroy bacteria in the skin. Light energy is converted

into heat which kills the bacteria and probably degrades some

of the infl ammatory materials in the hair follicle. Lasers and IPL

may also target oil glands themselves, reducing the produc-

tion of sebum. Both of these treatments may shrink the size of

pores, thereby improving their appearance.

These treatment alternatives for acne take about 15 minutes,

and may be performed by a dermatologist, a physician’s assis-

tant, or a nurse. Costs vary from $200 to more than $500 per

treatment, so it is important to discuss this with the dermatolo-

gist before beginning treatments. Many insurance companies

cover some types of treatment but not others, so if you use

insurance for your dermatologic care, you should fi nd out in

advance whether your treatments will be covered. Treatments

are repeated at intervals of two and four weeks.

Photodynamic Therapy (PDT)

Complications of oral medications have sparked interest

into non-antibiotic treatments. Photodynamic therapy com-

bines light or laser with topical dyes to safely and effectively

treat acne.

The dye used for PDT is known as aminolevulinic acid.

This product is painted onto the skin where it is metabolized

into a substance (protoporphyrin) that reacts with light.

This reaction generates reactive molecules that kill bacteria.

Typical schedules for the treatment of acne include monthly

treatments for about four to six months. Success rates for

this treatment are impressive although more research will

most likely increase them even further.

For more information on photodynamic therapy, see

Chapter 6.

Maintaining Clear Skin When You Have Acne

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Daily Care for Acne Prone Skin

“Taking care of acne prone skin is complicated and involves

coordinating washing and application of many products.”

My recommendation for acne prone skin is to fi nd products

that you like and stick with them. Oily skin will typically

benefi t from a salicylic acid wash and salicylic acid pads used

twice a day. Skin that is dry or normal can use a mild, fragrance-

free cleanser once or twice daily. Products that are not clearly

labeled as being “non-comedogenic” or “non-acnegenic” should

be avoided, as they may worsen the very problem you are try-

ing to treat. Products in my Palm Beach Esthetic Center Line

include salicylic acid wash and salicylic acid pads, benzoyl per-

oxide products, and mild cleansers. Non-comedogenic moistur-

izers are also included for the occasional bout of skin irritation.

DR. BEER’S DAILY ANTI-ACNE REGIMEN

1. Do not squeeze or pick at acne, which can cause scarring.

You will not make the lesions go away by scratching them off

2. Gently wash your face once or twice a day with an acne

wash such as Neutrogena, Purpose or the Palm Beach
Esthetic Center Cleanser. Avoid vigorous scrubbing

3. If your skin is oily or you have a lot of blackheads use an

acne treatment pad that has salicylic acid. These are avail-
able from a variety of sources including idealskin.com

4. Use only non-comedogenic, non-acnegenic products on

your skin

5. Avoid products and foods that cause your acne to fl are up

6. Be patient. If your dermatologist is treating your acne with

topical or oral medications or photodynamic therapy, give
them some time to help your skin. If the medications cause
side effects, discuss them with your dermatologist. Do not
simply abandon medications, doctors, or procedures. Doing
this will simply waste your time and your dermatologist’s time

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CHAPTER

Common
Conditions
That Interfere
with the Perfect
Skin Plan:

Rosacea, Sensitive Skin,
Eczema, Psoriasis

“At certain times, all skin types may

be prone to reactions from various

internal and external sources.”

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Rosacea

Rosacea is a complicated disease affecting 14 million Americans.

Research shows that many of these people do not know that

they have rosacea or that treatments are available for this disease.

Rosacea is typically seen in people with fair skin such as those

with Scotch and Irish skin types. Hormones play a strong role in

the development of rosacea, and many women notice rosacea

fl ares around their menses or with the onset of menopause.

There are many different sub-types and appearances of

rosacea. Most people with rosacea have pus bumps and tel-

angiectasias. These broken capillaries are frequently the most

conspicuous and embarrassing aspect of rosacea because of the

perception that this disease is linked to excessive alcohol con-

sumption. Telangectasias will worsen with repeated sun expo-

sure, spicy foods, or alcohol consumption. Fortunately, treatments

such as lasers and intense pulsed lights are widely available.

Treatments for rosacea range from topical antibiotics, to topi-

cal Retin-A

to oral medications to meditation to lasers. Most der-

matologists will begin treatment with a topical antibiotic such as

metronidazole (Metrogel). This product is available in gel, lotion,

and cream forms, and it has a long history of safety. Recently, der-

matologists have begun to use another topical medication called

Finacea with increasing frequency. This drug has been demon-

strated to improve many forms of rosacea. Clinical trials combin-

ing Finacea with low dose oral doxycycline (Oracea) have begun

to see whether this combination will be effective.

An interesting new potential treatment was suggested in

a recent article by Drs. Michelle Pelle GH Crawford and WD

James.

This article suggests that Retin-A

, which was consid-

ered to aggravate rosacea, can actually signifi cantly improve

many types of rosacea.

Severe forms of rosacea require oral antibiotics. These may

include products from the tetracycline family such as doxy-

cyline, minocycline, or tetracycline. As previously discussed in

regard to acne, each of these medications is subtly different, and

J Am Acad Dermatol. 2004 Oct;51(4):499-512;)

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each has its own risks and benefi ts. For instance, doxycyline can

increase the risk of sunburn and irritate the esophagus, so it

should never be taken just before going to bed. Minocycline may

cause dizziness, discolor teeth, and make skin appear blue-gray.

Tetracycline must be taken an hour before meals or two hours

after meals. Oracea is another promising drug for which I have

done some clinical trials. This is a low dose of doxycyline, and it

works by a mechanism entirely different from the same medica-

tion when given at higher doses. In the low (or subantimicro-

bial) dose, doxycyline inhibits enzymes responsible for rosacea

fl are ups. More research needs to be done in this area, but this

regimen may offer patients the opportunity to avoid the side

effects seen with traditional doses of antibiotics.

My rosacea patients who start therapy with oral and topical

antibiotics are weaned from the oral medications over the span

of a few months whenever possible. If you are pregnant, nurs-

ing, or planning to become pregnant, you should avoid taking

many of the medications used to treat rosacea with the excep-

tion of topical erythromycin.

Pulsed dye laser and intense pulsed light are great treatments

for rosacea. The pulsed dye laser is better for thicker blood ves-

sels but leaves bruising and swelling for a few days, while the

intense pulsed light is better for diffuse redness with fi ne vessels.

Future treatments for rosacea may include new low dose

antibiotics, photodynamic therapy, and lasers. Fortunately, even

though the etiology is not well defi ned, the treatments for

rosacea are very good and most patients control their symptoms

with quarterly visits to their dermatologist and daily medications.

The large bulbous nose and other excessive oil gland

proliferations associated with rosacea may do well with oral

and topical antibiotics but sometimes require procedures to

remove the excess oil glands. Lasers and electrocautery devices

typically do quite well in these cases.

Daily Care for Rosacea Prone Skin

Daily care for rosacea prone skin is quite different from daily

care for normal skin types. Some types of rosacea will fl are

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PALM BEACH PERFECT SKIN

up with application of rich emollients or astringents contain-

ing alcohol, and these should be avoided. Utilize mild cleans-

ers such as Neutrogena Foaming face wash, glycerin based

soaps, Purpose, or Palm Beach Peel

Green Tea Cleanser. Palm

Beach Peel

Green Tea Serum is rich in antioxidants and many

patients fi nd that this calms their rosacea and helps them to

avoid medications.

Products with glycolic acid or a high percentage of alcohol

should be avoided as they tend to make your skin redder. A skin-

care journal may help you to identify triggers that make your

skin worse. If you elect to keep a skincare journal, note what

foods you eat to see if there is an association with fl are ups.

To avoid increased prominence of dilated blood vessels,

avoid anything that causes your facial skin to become red or

irritated. Sun exposure is one leading cause of redness. These

products contain minimal alcohol and other chemicals, which

tend to irritate the skin.

Variants of rosacea are common, and they are commonly

misdiagnosed. One of the most widespread variants is known

as perioral dermatitis. I usually see people with this condi-

tion after their primary care physician has treated them for

a few months with various cortisone creams and antifungal

medications. Perioral dermatitis is notable for small pimples

located around the mouth. The telltale sign of perioral derma-

titis is pimples that typically spare a small rim around the lips.

Although there are no studies to prove this, many patients ben-

efi t when they switch from tartar control toothpaste to Tom’s

of Maine or another brand that has few additives. Topical or

oral antibiotics are also helpful in treating perioral dermatitis,

and they are a cornerstone of my initial therapy.

Sensitive Skin

Sensitive skin is easily irritated and frequently red and

infl amed. It is prone to blemishes, fl akiness, chafi ng, and crack-

ing. Patients often complain that their infl amed skin feels

uncomfortably tight and that it burns or stings. The underly-

ing infl ammation may be due to dry skin, psoriasis, sebor-

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rheic dermatitis, contact dermatitis, eczema, or any one of a

few hundred conditions that result in red irritated skin. Many

people with sensitive skin have fair skin that burns easily in

the sun and is irritated by products used for treating aging skin

or acne (especially those containing glycolic acids or benzoyl

peroxides). Allergies may make the skin sensitive. They may be

triggered by a neighbor burning poison ivy or sumac, or by the

chrysanthemums sitting in a vase at your dining room table.

A recent patient had a rash that covered his entire body for

over three years. He had seen many dermatologists and had many

treatments, none of which helped for more than a few days. The

extent of his skin irritation effected his quality of life as well as

his health. After speaking with him and performing skin biopsies

to rule out psoriasis and some types of skin lymphoma known as

mycosis fungoides, I asked him how he spent his day. I inquired

about which fl owers and plants he had in his house. When he

returned the following week, I learned that two of the plants

had been irritating his skin because he was allergic to them. He

got rid of the plants and the skin irritation. Other patients are

irritated by newspaper ink, dyes found in leather, coins in their

pockets, and wooden handles from knives in their kitchen.

Treatments for sensitive skin are varied and they depend

on the cause of the sensitivity. No matter what the etiology of

the sensitive skin, scratching is the worst thing to do. Avoid

scratching and instead apply ice or Sarna or Aveeno Itch

lotions. Oatmeal can be very helpful in soothing irritated skin

but do not try to put Quaker Oats into a bathtub (as one of

my friends did). Rather, invest in Aveeno Oatmeal for bathing.

Depending on the level of sensitivity, your dermatologist may

prescribe topical steroids or drugs such as Elidel or Protopic to

help calm the skin. In addition, antihistamines and oral steroids

may be needed in severe cases.

Skincare for sensitive skin should focus on the minimalist

approach: less is more. Do not purchase products with a laun-

dry list of ingredients that are not designed for sensitive skin.

Use soaps and detergents that are fragrance free (even though

some that are labeled as such are not truly fragrance free but

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PALM BEACH PERFECT SKIN

mask the use of a fragrance as a preservative). The fewer the

ingredients, the safer you are. Keep a diary of products and

your reaction to them to try to help determine a program that

works for you. One misconception is that very hot water helps

sensitive skin. Hot water will actually remove the natural pro-

tective oils of the skin and make the skin more prone to infec-

tion and irritation. Warm water and soap-free cleansers used

once a day are the best way to minimize irritation if you have

sensitive skin. A thin layer of hypoallergenic moisturizer should

be applied to the skin while it is still moist. To help maintain

the skin’s integrity, sleep in a room with a humidifi er when you

are in a dry environment.

Eczema (Atopic Dermatitis)

Atopic dermatitis or eczema affects between 10 and 20

percent of the world’s population, with about 15 million

people affected in the United States, according to the National

Institute of Health. Many people with eczema do not even

realize that they have the disease. They frequently see a non-

dermatologist who diagnoses them with “dermatitis” (transla-

tion: it itches and we do not know why) and treats them with

whatever cream is in fashion that month. Signs and symptoms

of eczema include a family or personal history of asthma or

hay fever (which frequently accompanies eczema) and itching

in folds of the elbows, sides of the neck, and behind the knees.

An extra crease in the lower eyelid (known as a Denny-Morgan

pleat) and extra lines in the palms of the hands may indicate

eczema in children. Many patients with eczema notice small

bumps on the sides of their upper arms and thighs. These

bumps are known to dermatologists as keratosis pilaris and are

actually hair follicles clogged by epidermal cells. Treatments

for this condition, which is worse in dry environments, include

topical moisturizers with lactic or glycolic acids (AmLactin, Lac

Hydrin, Palm Beach Esthetic Center Glycolic Body lotion and

cleansers from Idealskin.com). Urea based products as well as

topical steroids and Retin-A® may also be helpful for treating

this condition.

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Eczema is a chronic, infl ammatory skin disorder resulting

from an immune response. Its treatment is evolving. In my

practice I rely on oral antihistamines including: Claritin, Zyrtec,

Zantac, and others. Drugs such as Singulair (which blocks

infl ammatory transmitters) are also helpful with eczema and

frequently decrease the symptoms of asthma that accompany

eczema. I rely on topical medications, including topical ste-

roids and immunomodulators such as Elidel and Protopic, to

control eczema in the majority of my patients. Despite recent

news reports about Elidel and Protopic, I believe they are safe

for use in children when used for appropriate amounts of time.

Despite treatment with aggressive oral and topical medica-

tions, some people fail to improve. Many of these patients have

bacterial infections which limit the skin’s ability to heal. Using

antibiotics that treat Staphylococcus and Streptococcus will

dramatically improve eczema fl ares in these patients. Patients

with recurring infections will need to have their nostrils

cultured because this area is a frequent harbor for bacteria.

Topical antibiotics such as Bactroban are helpful in reducing

the presence of bacteria for affected patients.

Future treatments for atopic dermatitis will target the

infl ammatory cells that cause the disease and will be more

targeted than present therapies. For the many patients with

eczema, this will be a welcome relief.

Psoriasis

Psoriasis is a chronic autoimmune disease (the body’s immune

system is attacking itself) and affects approximately two per-

cent of the American population. Highly visible, thick, red, scaly

infl amed patches on the skin are the stigmata of this disease.

Because of the huge physical, emotional, and fi nancial bur-

den imposed by this disease, it consumes a great deal of time,

effort, and money. Moderate to severe psoriasis may be associ-

ated with lowered self-esteem, days lost from work, moderate

to severe depression, and debilitating arthritis. Psoriasis is not

contagious (despite popular beliefs to the contrary), but it

defi nitely impacts those that help care for patients.

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PALM BEACH PERFECT SKIN

Patches of psoriasis may be small and limited to one part of

the body (such as the elbows) or they can be large and cover

the entire body. Common sites for psoriasis include the elbows,

scalp, knees, buttocks, and nails. However, the disease may

have varied presentations and may affect any part of the body

including the tongue.

Psoriasis is mediated by immune cells known as T lympho-

cytes. These cells communicate with other immune cells and

epidermal cells, signaling them to proliferate in a very abnor-

mal manner. Many treatments for psoriasis work by shutting

down parts of the immune system. This explains why so many

psoriasis drugs began as drugs used for organ transplantation.

Topical steroids, which are still a mainstay of therapy, affect

several parts of the immune system. Other topical treatments

include vitamin D analogues such as Dovonex. Ultraviolet light

treatments function by diminishing the immune cells in the

skin, and are effective in treating psoriasis. Light therapy may

involve ultraviolet B (either as a broad or narrow band) or

ultraviolet A (which is used in conjunction with an oral medi-

cation known as psoralen to boost its effectiveness).

Newer treatments involve biologic modifi ers, which target

specifi c immune cells or molecules used for cellular commu-

nication. These drugs (including Enbrel, Raptiva, Amevive, and

Remicade) are exciting new therapies for psoriasis, but I do not

use these drugs with great frequency as I have some concerns

over the long-term safety data of several of them. Methotrexate

is a chemotherapy drug that has a long history of effective-

ness in treating psoriasis, although it may damage the liver and

requires liver biopsies when used for long periods of time.

Other medications used for the treatment of psoriasis

include cyclosporine, a drug used for suppressing the immune

system following organ transplantation. This medication may

affect the kidneys which is a frequent limiting factor in its use.

Future treatments for psoriasis may involve topically applied

biologic modifi ers, lasers, or medications that inhibit immune

cells as they traverse the skin.

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CHAPTER

Lasers & Light
Sources:

The New Waves

“There will soon come a time

when lasers will dominate all

cosmetic practices.”

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PALM BEACH PERFECT SKIN

Laser technology is improving every year, but it is still

worth considering the pronouncement of one of the lead-

ing laser surgeons, who remarked that: “Lasers are

not erasers

.”

To best understand which lasers or light sources might

be helpful in obtaining perfect skin, it is worthwhile to

fi rst understand what these devices are and how they

work. A laser is a high energy light beam that is extremely

focused and capable of delivering high amounts of energy

to a small area. These devices have revolutionized cosmetic

dermatology by targeting particular colors or molecules.

This ability enables dermatologists and plastic surgeons to

perform light based surgery at a microscopic level. When

undergoing laser treatment, it is important to have the cor-

rect device selected since different devices target differ-

ent molecules. For instance, the red hemoglobin found in

blood vessels is best treated by a pulsed dye laser while the

brown pigment found in freckles is typically best treated

by YAG laser. In order to remove sun damaged skin, lasers

absorbed by water might be utilized to vaporize the dam-

aged layers. Other light sources, such as intense pulsed

lights, deliver energy capable of treating many different

skin problems. However, they are not technically lasers.

The popularity of lasers arises from the fact that they

are able to provide a high degree of selectivity in cosmetic

dermatology. Lasers of different colors (frequencies) and

energy levels can treat a variety of skin problems including:

unwanted hair, acne, port wine stains, scars, psoriasis, skin

cancers, tattoos, blood vessels, wrinkles, laxity of the skin,

freckles, scars, and stretch marks.

If you are considering laser or intense pulsed light treat-

ment, it is important to consider your goals, your budget,

and your tolerance for downtime and risk. Each of these

is a factor in deciding which treatment to have, and they

should be discussed with your physician prior to beginning

a treatment.

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Lasers for Skin Rejuvenation

The two main categories of lasers used for skin rejuvena-

tion are ablative and non-ablative. Ablative techniques

utilize CO2 or Erbium light sources to ablate (destroy) the

outer layers of skin. These lasers target water found inside

the cells of the skin and vaporize them. After this proce-

dure, the skin replenishes itself using epidermal stem cells

located deep within the hair follicle. This procedure is a

controlled burn, and it has many of the risks associated with

a burn, including scar formation, changes in pigment and

infection. Used by the right physician on the right patient,

CO2 or erbium lasers offer dramatic results. However, the

complication rate has curbed enthusiasm among many cos-

metic dermatologists and plastic surgeons.

Non-ablative (“cold”) techniques use lasers that pass

through the skin without vaporizing it. These devices heat

collagen and other connective fi bers to tighten the skin. Non-

ablative techniques carry fewer risks than ablative techniques

but require several treatments. New non-ablative “miracles”

pop on the market about every two years with claims that

compare them to facelifts without the surgery. Typically,

these devices are popular for a year and are then replaced by

the next fad. When considering one of these new “miracle”

devices, it is worth asking about which publications back up

their claims. This will help to determine which devices merely

have good marketing but little to no proof of effi cacy.

Future directions for laser skin rejuvenation will most

likely remove skin layers in a more gentle and precise

method and will tighten collagen and elastic fi bers to a

greater degree and with a better safety profi le.

Non-Laser, Light Based Rejuvenation:

Intense Pulsed Light, Radiofrequency,

Photodynamic Therapy, LED, and Fraxel

™

Energy can be delivered to the skin using lasers, light, sound,

microwave, and many other sources. The non- laser systems

Lasers & Light Sources

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PALM BEACH PERFECT SKIN

described here tend to rejuvenate with minimal destruction

and minimal downtime.

Intense Pulsed Light

Intense pulsed light (IPL) is exactly what it sounds like:

intense light. It differs from a laser—which utilizes coherent

light of a single color (wavelength)—by using light that is

neither coherent nor of a single wavelength.

Different wavelengths (colors) of light interact with the

skin in different ways. To treat red discolorations of the skin

(such as telangectasias or rosacea), light or laser absorbed by

the color of hemoglobin (found within the blood vessels) is

the best choice. Freckles, brown spots, and unwanted hair

may all be treated with light of a different color. Skin tighten-

ing is accomplished with lights that tighten the collagen and

elastic fi bers by gently heating them. To accomplish specifi c

goals, most intense pulsed lights have different hand pieces

that emit different colors of light. In my practice we use a

device that is so well received that there is a waiting list to

get an appointment for treatment. Intense pulsed light is also

helpful for treating acne and actinic keratoses, and it may be

combined with Levulan for increased effi cacy. IPL has also

been helpful in treating age spots on the face and hands as

well as for the treatment of neck discoloration that is preva-

lent in Florida. The next generation of IPL devices has the

promise to deliver signifi cantly better wrinkle treatments as

well as treatment for unwanted hair.

Typical IPL treatments are performed every three to six

weeks and a series of four to six treatments is recommended.

Costs vary depending on the location being treated. An aver-

age treatment for the face is approximately $500. Expect to

pay more for a quality device used under the supervision of

a dermatologist. Minor discomfort—comparable to a rubber

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band snapping on your skin—is typical for treatment with

IPL. Following a treatment, dark spots may appear darker as

they lift through the skin and migrate off. Red lesions may

appear slightly bruised. Treatments for skin tightening or

acne may look like a mild sunburn for a few days. Follow-

ing IPL treatments, you should expect a more even tone and

texture. Treatments for acne and rosacea produce gradual

improvements over the span of a few months.

A note of caution: The use of these devices has become a

recent trend among centers run by non-dermatologists

and non-plastic surgeons. The risk for problems increases

when IPL lasers are used by doctors who do not possess the

training to understand how to use these devices properly;

so be wary of the gynecologist or allergist who wants to

laser your skin.

Radiofrequency Waves

Like light, radio waves may be used to deliver energy to the

skin. They have been successfully used for years to tighten

the skin, and newer devices appear to have a great deal of

potential. Radiofrequency devices deliver a precise amount

of energy to an exact portion of the skin without injuring

the layers above it. Energy is produced by a radiofrequency

generator instead of a light source, and a cooling device

delivers coolant to protect the skin. Thermage

, the most

recent innovator in this fi eld, uses a computer to create a

“layer” of energy with a consistent shape that is delivered to

a particular location on the skin. In theory, this means that

the energy is precisely delivered to the intended location

without interfering with the layers of skin above or below

it. Thermage

is a good fi rst step in focused energy deliv-

ery. Patients undergoing Thermage

typically describe it

Lasers & Light Sources

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PALM BEACH PERFECT SKIN

as moderately painful, so oral and topical medications are

often used to relieve discomfort. Some of my patients who

have had this procedure experienced mixed results, ranging

from no appreciable difference to signifi cant changes. I do

not know if the variation refl ects differences in the experi-

ence of the physician using the device, or variations due to

patient skin types and settings used.

Syneron Elos

™

System

Electro-optical synergy (ELOS) delivers energy by combin-

ing radiofrequency with light waves. This unique system

treats unwanted hair, acne, wrinkles, and telangectasias safely.

To date, they are considered “lunch time” procedures with

minimal downtime and a mild amount of risk. I believe that

this technology has a great deal of promise for the future,

including the potential to treat cellulite effectively.

Photodynamic Therapy

Photodynamic therapy (PDT) marries intense light or laser

with an energy absorbing chemical. This treatment was fi rst

used for precancerous actinic keratoses but is now used to

treat acne, wrinkles, sun damage, large pores, and prominent

oil glands. In photodynamic therapy, light interacts with Levu-

lan (5 aminolevulinic acid) painted on the skin. This interac-

tion generates reactive oxygen that kills nearby cells. The

remodeling that follows replaces the damaged cells with new

ones derived from follicular stem cells. PDT is in its infancy.

However, I think it will be great for early skin cancers, cancers

that are unrelated to the skin, and for cosmetic uses.

If you plan to undergo photodynamic therapy, your skin

will fi rst be cleaned to remove dirt and oil which can impair

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penetration of the dyes. The Levulan will be painted onto

your skin for anywhere from 15 minutes to 12 hours. Then

a light (most commonly a specialized device known as

Blu U), laser, or IPL will be used to activate the Levulan.

Afterwards, the skin will look and feel as though it was

burned by the sun. Since the procedure may activate cold

sores, it is important to let your dermatologist know if you

have a history of outbreaks so that he or she may prescribe

medication to decrease the risk of a new outbreak. You

should also tell your doctor if you are taking thiazide diru-

retics or antibiotics (such as doxycycline) that might react

with light.

Perfect Skin Hint: Following treatment, mild emollients such

as Palm Beach Peel® Green Tea Serum and chemical-free

sun block should be used to help the skin heal.

LED Technology

Light emitting diodes (LED) use low light energy to stimulate

the skin to promote renewal. This technology is exciting

because it does not generate heat or damage the skin. One

LED device already on the market is GentleWaves

, and

this has been shown to increase collagen production and

decrease the activity of enzymes (collagenase) that break

collagen down. The procedure lasts only a few seconds, is

painless, and has no downtime. It can be used with low dose

antibiotics (which also inhibit collagenase), chemical peels,

microdermabrasion, fi llers, and Botox

. For these reasons,

moving into the future I believe that LED will play an

increasingly large role in cosmetic dermatology.

Lasers & Light Sources

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PALM BEACH PERFECT SKIN

Fractional Resurfacing Including Fraxel

™

Fractional resurfacing refers to a process known as frac-

tional photothermolysis to resurface the skin in tiny incre-

ments. The fi rst system to do this is known as Fraxel

™

and it

was made by Reliant. Fraxel

™

has been likened to improving

the picture on a television screen one pixel at a time. Instead

of removing all of the skin, this system uses microscopic

laser wounds which spare intervening skin. This enables the

skin to repair itself rapidly and reliably. Fraxel

™

and other

fractional thermolysis systems including those made by Palo-

mar and other manufacturers are in-offi ce treatments. They

require topical anesthesia for pain control. Most patients

experience a mild sunburn sensation that lasts about an hour

after the treatment. The skin remains pink for fi ve to seven

days following treatment. Epidermal regeneration is rapid,

beginning within 24 hours of the treatment. After a treat-

ment, the use of sun block and antioxidants such as green

tea will help to protect and nourish the regenerating skin.

Many more fractional thermolysis devices are scheduled for

release in the near future, and they should bring interesting

improvements with each generation.

SUMMARY OF LASERS, IPL, AND LED DEVICES

Device Type

Brand Names

Application

LED

GentleWaves, Omnilux,

MediLite, Revitalight

Skin rejuvenation,

acne

Erbium:YAG

MediDerm, FriendlyLight,

Venus, Profi le Contour,

Profi le S Contour, Burane

Skin rejuvenation,

wrinkle reduction

Nd:YAG

Cooltouch, Varia, Vas-

culight, CT3, CoolGlide

XEO, CoolGlide Vantage,

Genesis Pulse, SmartEpil

II, Acclaim 7000, TriStar,

Skin rejuvenation,

vascular therapy,

wrinkle reduction,

pigmented lesions,

veins, hair removal

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Device Type

Brand Names

Application

Nd:YAG

Apogee Elite, Friendly

Light, Medlite C3, Lyra I,

Gemini, VascuLight Elite,

Lumenis One, StarLux

System, Profi le-ClearScan,

Profi le ThermaScan,

Profi le-S ClearScan, Profi le

–S ThermaScan, Profi le-D

ClearScan, MYDON,

GentleYAG, VARIA,

Coolglide Excel, Coolglide

Vantage, IPL Quantum DL,

Harmony, Profi le Consul,

Profi le 1064 Module, Solo

1.0 + chiller

Pulsed Light

CoolGlide XEO, XEO SA,

Genesis Plus, PhotoLight,

Quadra Q4, IPL Quantum

SR, VascuLight Elite,

Lumenis One, Prolite II,

EpiCool-Platinum HRSR,

MediLux System, EsteLux

System, NeoLux LuxY,

StarLux System, Profi le

BBL, Profi le-S BBL

Skin rejuvenation,

vascular treatment,

pigmented lesions,

veins

Pulsed Dye

PhotoGenica V, TriStar,

Vbeam, N-Lite V, Cbeam

Skin rejuvenation,

vascular treatment

Q-Switched Ruby

Medlite C3, Q-switch:

YAGk, SINON, Medlite C3

Pigmented lesions,
skin rejuvenation,
vascular treatment

Diode

LightSheer, Smootbeam,

Fraxel™ SR, Galaxy, Po-

laris WR, Quantel Viridis

Skin rejuvenation,

vascular treatment

Alexandrite

GentleLase, Apogee Elite

Pigmented lesions,

skin rejuvenation,

vascular treatment

Lasers & Light Sources

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PALM BEACH PERFECT SKIN

Combination Treatments That Work
in Conjunction with Laser, LED & IPL

People who want to look better never have a single issue they

wish to correct. Each person requires his or her own solution,

which is why cosmetic dermatology is never boring.

FREQUENTLY USED COMBINATIONS

Combination Therapy

Logic

Botulinum Toxin & Fillers

Wrinkles due to muscle actions
are relaxed by botulinum toxin
(Reloxin

, Botox

) while fi llers puff

out the wrinkles caused by tissue
loss. Minimal downtime and risk.

Botulinum Toxin & IPLs

IPL helps to improve the tone and
texture of the outer layers of skin
while botulinum toxins decrease
the wrinkling. High yield with low
downtime and low risk.

IPLs & Microdermabrasion

Both will help with surface texture
and pigment irregularity by using
different techniques so adding
them together is helpful.

Microdermabrasion & Peels

Microdermabrasion and peels both
are used for resurfacing and can
be combined to harness some of
the benefi ts for each. Great for skin
that has a lot of sun damage.

Botox

, Fillers, IPL,& Palm

Beach Peel

Products

The “blue plate special”—this
combination addresses lines due
to muscle movement, wrinkles
from volume loss and sun damage,
while providing the tools to main-
tain the benefi ts between visits to
the offi ce.

Fat Transfer & IPL

Fat transfer allows for large volume
restoration while IPL restores the
luster to the surface.

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CHAPTER

All About
Botulinum Toxin

“Botulinum toxin revolutionized

cosmetic dermatology and

dermatologic surgery in ways

that few procedures before or

since have done.”

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I have learned a great deal about botulinum toxins from

some of the leaders in this fi eld including Tom Rohrer, Ken

Arndt, Jeff Dover, and Alastair and Jean Carruthers, as they

have graciously allowed me to collaborate with them on

books such as Procedures in Cosmetic Dermatology

(Elsevier 2005).

Botox

is the most popular cosmetic procedure for good

reason. The drug has a long (approximately 20 year) history

of safety and effi cacy for many indications. Yet few proce-

dures are more widely misunderstood than the injection of

botulinum toxins. To that end, I will attempt to separate fact

from fi ction regarding botulinum toxin, and clarify what it is

and what it can and cannot do.

What Is the Difference Between
Botox

, Myobloc

& Refl oxin

Botox

, Reloxin

and Myobloc

are different types of

Botulinum toxin. Botox

and Reloxin

are type A, while

Myobloc

is a type B. They are different in how long they

last, how fast they begin to work, and how much they cost.

All botulinum toxins work by relaxing muscles that cause

wrinkles.

Botox

and Reloxin

are highly purifi ed proteins

manufactured the same way as other bio-engineered drugs.

Despite what your hair dresser, nail tech, or neighbor

says, there are no bacteria in a bottle of either Botox

Reloxin

. Each product arrives as a freeze-dried powder

that must be reconstituted before it can be injected. The

container is sealed to make tampering impossible. Each box

is also sealed, and there is a holographic image and serial

number on each bottle to prevent copying of the product.

Botox

and Reloxin

doses are measured in units, not

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syringes. If someone is selling you a “syringe” of Botox

or Reloxin

at a discount, you need to make sure that it

is the product you think it is and inquire as to the number

of units it contains. Purchasing a cheap treatment that has

only a few units is no deal, and unfortunately, some marginal

cosmetic injectors will dilute their products to increase

their profi ts.

Each bottle of Botox

contains 100 units and each physi-

cian dilutes these 100 units differently. Many dermatologists

use 2 cc of saline to reconstitute the Botox

. Others use 4

cc, and still others use as much as 10 cc to dilute each bottle.

Obviously, the bottle diluted with 10 cc will be able to be

used on many more people than the bottle diluted with 2 cc,

and each person that gets a “syringe” from the 10 cc bottle

will only get 10 units. This results in a Botox

treatment that

“does not work”. Any time you have something injected,

into your body, common sense dictates that you should fi nd

out what the product is, how much of it is being injected

and where it came from. Injections of Botox

or Reloxin

should only be done by a dermatologist, plastic surgeon,

oculoplastic surgeon or head and neck surgeon who has the

knowledge and experience to understand the anatomy of

the areas being treated. These simple guidelines will ensure

safe and effective treatments.

How Botulinum Toxins Work

Once injected, botulinum toxin is taken up by the nerves

at the site of injection. After absorption, it blocks transmis-

sion of a chemical (acetylcholine) from a particular nerve to

the muscle that it controls. Without this signal, the muscle

relaxes and the wrinkle it caused begins to fade. No poi-

soning occurs during this procedure and no infection is

All About Botulinum Toxin

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PALM BEACH PERFECT SKIN

possible from the material, which is a freeze dried powder.

The process is a simple interruption of the communication

traffi c between a nerve and the muscle it controls. Botox

and Reloxin

are not permanent because the nerves begin

to sprout new connections to the muscle after a few months,

and the muscle once again begins to contract. Only motor

nerves and nerves that control sweating are affected leaving

the sensation for the area intact.

Wrinkles such as those found in frown lines, crow’s feet,

forehead lines, and deep smoker’s lines are caused by muscle

contractions. Relaxing the muscles involved allows the

wrinkles to relax. Typical injections of Botox

or Reloxin

take about two minutes to perform. Many physicians apply a

topical anesthetic prior to injection to minimize any discom-

fort. An average treatment of the crow’s feet involves about

four small injections on each side while treatment of a frown

line will involve about fi ve injections. Injecting a forehead

is more variable since some people have high foreheads

and require a brow lift while others have a low forehead

and want fl at brows. A Botox

brow lift is performed by

injecting muscles that pull the eyebrow downward, allowing

opposing muscles to raise the brow. Over the past few years,

this has become one of the most popular indications for

Botox

injections in my offi ce.

Injections of the chin (correction of “scrotal chin”), neck

bands, and of down turned mouth corners have also become

quite popular. Injections to treat migraines and excessive

sweating are commonly done for patients affected by these

conditions. Deep “smokers lines” around the lip respond

beautifully to a small amount of Botox

, and while most

of my patients love the results some dislike the fact that

they may not be able to use a straw or participate in other

lip intensive activities. In my practice, the most commonly

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injected areas include those around the eyes, forehead,

frown lines, and neck. Most of my patients combine Botox

with other fi llers to maximize the correction, and I will

typically inject both in the same visit. Botox

should be

repeated at intervals of about three to four months and fi ll-

ers need to be repeated depending on the product used.

The amount of Botox

injected varies from person

to person. An average woman getting treated for frown

lines will have 25 units injected in each area treated. Men

typically require more (up to 35 units). Foreheads and crow’s

feet in women require about 25 units per area while lips

typically use about four units for the upper and the same

amount for the lower lip. Neck treatments are variable and

use anywhere from 25 to 75. The bands of the neck on most

people do well with between 25 and 50 units, although

some people need more.

It is important to realize that Botox

and Reloxin

treat-

ments improve with time and each subsequent injection will,

most likely, have a better effect and last for a longer amount

of time. However, not every procedure will be perfect, even

in the hands of the best injectors. If you have a sub-optimal

treatment, discuss the situation with the physician who

performed your treatment. Botox

takes at least one week

to work fully and may require up to two weeks, so do

not despair if your treatment has not worked after a few

days. Reloxin

requires less time to work, typically only

a few days.

Other brands of botulinum toxin are used in Europe and

some of these will be approved for use in the United States

in 2006. One key difference among the various types of tox-

ins is that they may be different strains. Although each strain

works by the same mechanism, each type will perform with

greater or lesser effi ciency. Pricing for the various products

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PALM BEACH PERFECT SKIN

is also variable, and this greatly effects how much one should

expect to pay for a treatment.

Botox

was approved by the FDA in 2002 for the treat-

ment of glabella rhytids (frown lines) and in 2004 for

excessive sweating. Reloxin

(Dysport in Europe) will be

approved for use in early 2006. Botulinum toxin Type B is

used in Europe and may be introduced in the United States.

Each of these proteins is slightly different in terms of effi -

cacy, duration, and cost, but the addition of alternative treat-

ments will be welcome by physician and consumer alike.

After an Injection

Typically, there is minimal redness and swelling for a few

minutes after an injection. Rarely, there may be mild bruis-

ing, which can be worse when the areas around the eyes are

injected. This may persist for up to one week. I recommend

that my patients do not lie down or exercise for four hours

after an injection, but this is based solely on intuition. In order

to enhance the uptake of the protein into the muscles, exer-

cise the areas treated by smiling and frowning.

Complications reported after Botox

injections may

include bruising, headaches and fl u like symptoms. Fortu-

nately, these are rare and self limiting. One complication that

occurs in about two to three percent of patients is a droopy

eyelid. This occurs when the injection interferes with

muscles that hold the eyelid up. This problem lasts for about

two or three weeks, and eye drops will help restore the lid

to its normal position. In an effort to avoid this complication,

many physicians will not treat the lines immediately above

the eyebrow and prefer to stay about one-half inch above

that location.

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How to Avoid Problems with Botox

The fi rst rule of avoiding problems with cosmetic treat-

ments is simple: If you cannot afford quality cosmetic

dermatology or plastic surgery, do not have a procedure

done. Do not shop for a bargain when it comes to injecting

something into your body. If you are being injected with

Botox

, inquire about the physician’s training and the num-

ber of units of Botox

you will receive. Do not get injected

by someone who has not graduated from medical school or

who is practicing in an area in which they are not trained

and certifi ed.

In 2004, several patients in Florida ended up on life sup-

port after being injected with a toxin that was NOT Botox

at an offi ce that did NOT have a dermatologist, a plastic sur-

geon, or a physician who had an M.D. after his or her name.

They were injected with a product designed for research but

cheaper than Botox

. Although they saved some money, they

ended up on life support. The bottom line: get your cosmetic

treatments from a reputable physician practicing within the

specialty for which he or she was trained, and do not look

for bargains when seeking healthcare.

Limitations of Botox

Where Fillers Are Needed

Botulinum toxin is great for relaxing lines caused by mus-

cles, but it does nothing to replace volume lost with aging.

One example of this is the nasal labial creases (smile lines)

caused by loss of support structure and volume. For patients

for whom Botox

type treatments alone will not be suf-

fi cient, I combine fi llers with botulinum toxins. I frequently

use hyaluronic acids, collagens, Radiesse

™

, and fat. Each has

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PALM BEACH PERFECT SKIN

it own limitations and indications. For instance, I rarely use

Radiesse™ in the lips because I am concerned that it will

form nodules. Thin fi llers are a good choice for frown lines

because thicker ones have an increased risk of complica-

tions in this area. Thus, the choice of which fi ller to use in

combination with Botox

depends on many factors.

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CHAPTER

Fillers for Facial
Rejuvenation

“Until recently, facial rejuvenation

meant a facelift with the associated

risks, pain, and downtime. We are in

a new era of cosmetic dermatology

when safe and effective fi llers offer

compelling alternatives to surgery.”

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Fillers work by replacing soft tissue lost during normal

aging. To help visualize how they work, imagine that a

beach ball that has begun to lose air (to borrow a metaphor

from Dr. Gary Monheit). Various fi llers have different compo-

sition, longevity, side effects, and expenses associated with

their use.

Previously the high cost and low duration made the fi llers

approved for use in the United States limited in popularity.

Newer products are more durable, cost effective, and forgiv-

ing than those from previous generations and with their

advent, non-surgical alternatives to facelifts are increasing.

“The key to facial rejuvenation is the “Three ‘R’s”:

renovation of the surface texture, restoration of lost

volume, and relaxation of wrinkles.”

Before discussing particular fi llers in detail, let us begin

with a discussion of the history of fi llers, how fi llers work,

and the origin of a wrinkle.

A Brief History of
Soft Tissue Augmentation

Injection of various products into wrinkles has been

performed for at least a century. Early on, the treatment of

choice was fat, and this was particularly popular in the early

20th century. Fat transplantation is very popular at the pres-

ent time as cosmetic dermatologists and plastic surgeons

improve techniques enabling patients to have consistent

and durable corrections. Paraffi n enjoyed a brief window

of popularity until its high rate of deforming granulomas

became apparent. In the 1940s and ’50s, silicone injec-

tions were used to augment soft tissue. The love affair with

silicone continued for several decades until complications

removed it from the market. Recently, highly purifi ed silicone

has returned as a dermal fi ller. Fillers seem to cycle in and

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out of popularity, and this is something to consider when

deciding which product is appropriate for you.

The history of dermal fi llers can help you avoid some of

the “fl avors of the month” that although popular, can be also

quite dangerous. Understanding the pedigree of each fi ller is

important since some products may have been used safely

and effectively by reputable physicians in Canada and Europe

prior to introduction in the United States. This foreign experi-

ence often allows American physicians to select products with

known safety and effi cacy. Other products are used with mini-

mal experience within the dermatologic and plastic surgery

communities. These should be avoided.

Remember, although FDA approval does not guarantee

that a product is appropriate for you, some products are not

FDA approved for good reasons. Conversely, there are prod-

ucts which are not approved that are safe and effective.

How Fillers Work

Soft tissue augmentation products work by replacing differ-

ent materials lost over time. Imagine your skin as the beach

ball previously mentioned. It gradually loses air over time.

Sometimes a little puff can get back the original shape. Other

times, an air hose is required. Fillers run the gamut from puff

to air hose, and they can either smooth a few wrinkles or fi ll

deep hollows and creases. Each product has its own proper-

ties, and your particular needs and skin type will determine

which is appropriate for you. For deep wrinkles and creases

Perlane

, Juvederm

30, Restylane

Sub Q, and Radiesse

™

might be helpful. More superfi cial lines might be addressed by

Restylane

, Restylane

Touch, Hylaform

, Captique

™

, or Cos-

moDerm

. Sculptra

is part of a new category of fi llers that

stimulate the body to produce its own collagen. This tends to

provide a more durable correction than many other products.

Isolagen is a new product made from one’s own cells. These

cells are grown in culture, and they produce a matrix that can

replace collagen and other support structures.

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Before discussing each product in depth, let us answer a

few general questions about fi llers.

How Long Do Fillers Last?

Each product has its own duration. Some are short acting

(such as collagen, Hylaform

and Captique

™

). Restylane

Perlane

, Restylane

Touch and Juvederm® can last for

between six and twelve months (although I have seen

Restylane

last for as long as 16 months). Products such as

Radiesse

™

and Sculptra

may persist for years. Finally, fi llers

such as silicone and Artefi ll

are permanent.

What Are the Side Effects?

In general, injections are associated with minimal side

effects. The most frequent of these is bruising (which can

last for about one week) as well as the formation of small

bumps. People with a tendency to get cold sores may have

a fl are up when they are injected and should take antivi-

ral medications such as Valtrex or Famvir before getting

injected. Discomfort associated with the actual injection

may be minimized by the use of topical anesthetic creams

and dental injections to numb the areas being treated. Let

your doctor know if you are allergic to sulfa before anything

is applied to your skin, as some anesthetics contain sulfa

related compounds.

Lumps, bumps, and asymmetry may be associated with

any injection, no matter how skilled the injector. If these

occur with one of the non-permanent products, it will

disappear rapidly or can be treated. When lumps and bumps

occur with permanent fi llers, they are diffi cult to fi x and may

need to be surgically removed. Injections into the lips may

be associated with swelling that is impressive. This angio-

edema may be rapidly treated with steroids, antihistamines,

and ice. I tend to see bumps most frequently in the lips

because the small, corkscrew shaped glands (Fordyce glands)

get fi lled with whatever is being injected. Cleaning out these

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glands is simple and typically involves making a small nick

to extract the material. Subcutaneous papules (small white

bumps) may be seen in about three to fi ve percent of people

injected with Sculptra

How Long Is the Recovery?

Recovery time following soft tissue augmentation depends

upon the amount of material injected, the location of the

injection, and the type of material used. Patients tend to have

mild swelling after collagen, Captique

™

, Radiesse

™

, or Hyla-

form

, and slightly more swelling after Restylane

. When

more than 2 ml of any product is used, swelling occurs due

to the volume of material introduced into the skin. Bruising

and swelling are important considerations when scheduling

injections—although rare, the rate of complications seems to

increase the closer one gets to a major even such as a wed-

ding. If they occur, they can be covered with makeup such

as Physician’s Formula Green Cover, Dermablend, or Clinique

Continuous Coverage. Taking Advil, Motrin or generic ibupro-

fen (Costco’s brand is my favorite).

What Goes Where?

“Ultimately, the choice of what product goes where is

yours. The key to a good outcome is in selecting an

experienced injector.”

In general, products such as Restylane

, Perlane

, Juve-

derm

30, Sculptra

and Radiesse

™

tend to be good choices

for deep creases and areas that need long lasting correction,

as well as for sculpting cheekbones. Thinner substances such

as Restylane

Touch, Juvederm

18, Captique™, Hylaform

CosmoDerm

, and Zyderm

are appropriate for fi ne lines

and superfi cial wrinkles. Thinner products are also appropri-

ate for people with thin skin.

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PALM BEACH PERFECT SKIN

Before having soft tissue augmentation with any fi ller, dis-

cuss the duration, cost, risks, and benefi ts of the various options

under consideration. It is also important to inquire about the

experience and training of the person doing your injections.

Fillers in Detail

There are two basic types of fi llers: absorbable and non-

absorbable. The former are gradually broken down by the

body while the latter are not. Absorbable materials include

Hyaluronic Acids such as Juvederm

, Restylane

, Captique

™

Hylaform®, Collagen, Sculptra

, and Radiesse

™

Hyaluronic Acids

Hyaluronic acid gels have been widely used in Europe,

Canada, and South America to treat facial wrinkles and for lip

augmentation for about a decade. They are clear, viscous gels

made from sugar molecules strung together. These mole-

cules, normally found in skin, subcutaneous tissues, and joint

fl uid, are a normal part of the skin. During the manufactur-

ing process, the chains of sugar molecules are cross-linked

to provide stability. Without the cross-linkage, the molecules

would rapidly disintegrate.

The density of particles as well as the origin of the mol-

ecules account for the differences between various hyaluronic

acids. Hyaluronic acid may be manufactured (Restylane

Juvederm

and Captique

™

) or harvested from animal sources

(Hylaform

). No matter what their source, hyaluronic acid is

an ideal replacement for materials lost from aging skin.

Restylane

Restylane

was approved by the FDA in 2004, and its arrival

sparked a renaissance in soft tissue augmentation. Before

this, no safe and effective long-term correction was available.

To date, more than 1.5 million treatments have been per-

formed worldwide, and Restylane

remains twice as popular

as the next leading fi ller.

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Restylane

, Perlane

and Restylane

Touch are chemi-

cally identical gels cut up into different size particles.

Perlane

has 10,000 gel particles per ml; Restylane

has

100,000 gel particles per ml; and Restylane

Touch has

200,000 gel particles per ml. In order to understand this

concept, imagine a block of Jello being pushed through a

screen. If the screen size is larger, the particles will be big

(Perlane

). If the screen size is smaller, the size of the Jello

particles will be smaller (Restylane

). No matter how you

push the gel through the screen, it is the same gel when it

comes out. Since all hyaluronic acid products are gels, they

are malleable and allow for smoothing of the product after it

is injected.

Of the Restylane

family of products, only Restylane

presently FDA approved. It is wonderful for treating nasola-

bial creases (smile lines), lip augmentation, correcting frown

lines, and for scar revision. By injecting Restylane

—and

probably other fi llers—into the cheek bones, I can perform a

“Restylane

facelift”, restoring the mid-face to a more youth-

ful position. Restylane® Touch treats fi ne lines above the

lip (frequently seen in smokers) as well as those around the

crow’s feet. When used with tiny amounts of Botox

, dramatic

results may be achieved. Perlane

is wonderful for replacing

volume and for fi lling deep creases. Thicker than Perlane

Restylane

Sub Q, which will be used for deep tissue renova-

tion. As you can see, hyaluronic acid products are varied in

their composition and indications, and selecting the correct

product for your goals is part of having a great outcome—

there are few bad products but lots of bad injectors.

A Restylane

treatment begins with cleansing the area

and, usually, application of an anesthetic cream or injection

of a small amount of lidocaine or Septocaine into the gums.

The Restylane

is then gently and slowly injected. Once

injected, I mold or sculpt the product into the confi guration

that I want. Following the procedure, I usually apply ice and

tell my patients to take ibuprofen.

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Hylaform

and Hylaform

Plus

Hylaform

and Hylaform

Plus are hyaluronic acids made from

rooster combs. They are less dense than Restylane

and tend to

be softer and not as long lasting. The difference between Hyla-

form

and Hylaform

Plus is the size of the molecule. In addi-

tion, Hylaform

Plus is indicated for the treatment of deeper

wrinkles. In clinical trials, Hylaform

Plus lasted about half as

long as Restylane

for the treatment of smile lines. Approxi-

mately three months’ duration is typical for Hylaform

Captique

™

Captique™ is the same as Hylaform

except that it is manu-

factured rather than harvested from roosters. This allows the

product to be produced with no animal proteins, limiting

the potential for allergic reactions. Captique™ has the same

concentration, thickness, and duration as Hylaform

Juvederm

Juvederm

is a homogenous hyaluronic gel (in contrast to

Restylane

and Hylaform

which are particulate). It is pres-

ently approved for use in Europe but not in the United States.

Three versions are available: Juvederm

18, 24, and 30. They

vary in the concentration of hyaluronic acid. They also have

different indications, ranging from the treatment of deep

creases, to lip augmentation, and fi ne line fi lling. Juvederm

presently undergoing clinical trials in the United States, and I

am looking forward to using it when it is available.

Collagens

Collagen has been used to treat wrinkles since 1982 and

it was a revolution for cosmetic dermatology at that time.

Since collagen is the main ingredient of the dermal support

layer, it seems logical to use it to fi ll wrinkles. Collagen may

be harvested from cows (Zyderm

and Zyplast

), humans

(CosmoDerm

and CosmoPlast

), or cultured from the per-

son getting the injection (Isolagen).

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Zyderm

and Zyplast

Zyderm

, derived from cows, was approved for use in the

United States in 1982. Corrections with this product last

between three and fi ve months. Differences in bovine col-

lagen include different concentrations and cross linkage.

Zyderm

I has a concentration of 35 mg/ ml. Zyderm

has a concentration of 65 mg/ml. Zyplast

is cross linked

for additional stability. Injection styles also vary with each

material. Zyderm

I is injected into the superfi cial dermis. It

is useful for treating fi ne lines such as those around the lips

and eye. Zyderm

II is injected into the mid-dermis, and it is

helpful for slightly deeper lines. Zyplast

is placed into the

deep dermis and is intended for smile lines and deep wrinkles.

Each of these contains lidocaine for anesthetic. One techni-

cal aspect of injecting collagen requires more skill than some

other products is the overcorrection needed to compensate

for liquid mixed into the syringes. Since these collagens are

foreign proteins, allergy testing must be performed prior to

their use.

A collagen injection begins with cleansing of the skin.

Injections are made with small needles and the wrinkles are

overcorrected by anywhere from 50–100%. The degree of

overcorrection depends on the material selected and site

of injection. The decision of how much to overcompensate

depends on the skill and experience of the injector.

Human Collagen

Collagen harvested from cows is obviously foreign and one

alternative is human derived collagen. Human collagen may

be obtained from either cultured cells (CosmoDerm

and

CosmoPlast

), from cadaveric tissue banks (AlloDerm

and

Cymetra

), or grown from biopsies taken from the person

undergoing the treatment (Isolagen).

CosmoDerm

/CosmoPlast

These are similar to Zyplast

and Zyderm

in concentration

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PALM BEACH PERFECT SKIN

and cross linkage but are derived from skin cell cultures.

They contain lidocaine for anesthetic. One benefi t of these

products is that, unlike fi llers derived from cows, they do

not require allergy testing and may be injected on the day of

consultation. The duration of correction with these products

is between three to four months, making them fairly expen-

sive on an annual basis. CosmoDerm

and CosmoPlast

are

injected the same way as Zyderm

or Zyplast

, respectively

so an injector skilled with these latter products will be able

to inject the former ones with ease.

AlloDerm

and Cymetra

Neither of these has garnered a large share of the soft tissue

augmentation market. This is because neither has had stellar

results. AlloDerm

is human cadaveric dermis that has been

freeze-dried. Originally used for the treatment of burns, it is

processed in sheets and may be used for soft tissue augmen-

tation. It requires a surgical procedure to implant, and it lasts

about six to twelve months. I have never used this material.

Cymetra

is a micronized, injectable form of AlloDerm

It is reconstituted in the physician’s offi ce with lidocaine.

Like AlloDerm

, no allergy testing is required according

to the manufacturer, and no known hypersensitivity to the

product has been reported. Cymetra

is injected into the

dermis to treat deeper rhytids and acne scars. It is also

used in lip augmentation and produces a smooth result.

According to physicians who use the product, results typi-

cally last for between three to six months. I do not use this

product either.

Products Derived from Your Body

These products utilize cells obtained from a biopsy taken

from behind the ear and sent to a facility where it is cultured

and expanded. In the future, stem cells will be used to accom-

plish this, and a more long lasting correction will be obtained.

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Isolagen

Isolagen is made with cultured autologous (derived from the

person getting the material) fi broblasts to produce viable

connective tissue cells, collagen, and other products needed

for dermal support. The process begins with a 3 mm punch

biopsy typically taken from behind the ear. The specimen is

sent to the manufacturer where it is grown, and then shipped

back to the physician’s offi ce where it is injected into the skin.

This product makes sense to me, and I think it has great poten-

tial for long-term correction of soft tissue defects. Clinical trials

are underway that may eventually lead to FDA approval.

Volumizers:

Long-Term Soft Tissue

Augmentation

Sculptra

Sculptra

is the fi rst of a new category of products that

replaces lost volume by stimulating new collagen produc-

tion rather than by directly fi lling. Initially used to treat the

sunken faces of people with chronic disease, Sculptra

was

quickly adopted by cosmetic dermatologists. They realized

that it is an almost ideal product for long-term soft tissue

augmentation. Sculptra

works well in the temples, nasola-

bial creases, eyelids (“tear troughs”), scars, cheekbones, and

the backs of the hands. It is a sugar based molecule that has

been used for decades in the form of absorbable sutures.

Sculptra

has been used in Europe for a few years when

physicians there realized its potential for cosmetic usage.

Sculptra

is profoundly different from other fi llers. For

instance, there is no way to predict how much fi lling will

occur after an injection since each person produces a differ-

ent amount of collagen in response to the same injection. In

contrast with most injected materials, a Sculptra

treatment

is planned as several injection sessions, each spaced about a

month apart.

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PALM BEACH PERFECT SKIN

Another key difference is that a correction obtained with

Sculptra

is durable and can last for years. Potentially, Sculp-

tra

may restore volume to areas that have drifted south

or sunken in. For instance, it lifts the cheeks upward when

injected into the cheekbones. Sculptra

, like Botox

, is mixed

by the physician using it, and it does not arrive ready to inject.

This provides the physician using it with a variety of ways

to mix it. It also means that patients must inquire about the

concentration and amount they are receiving. As with Botox

some physicians will be concerned with providing patients

with optimal results while others will be concerned with

maximizing profi ts. Thus it is imperative that you understand

exactly what you are getting when you undergo treatment

with Sculptra

. Very dilute Sculptra

(or worse, a product

that is not Sculptra

) might save some money in the short run

but will not give you the results you are looking for. It can lead

to complications if the product is counterfeit.

A Sculptra

session begins with a thorough skin cleansing

using either alcohol or surgical scrub. Anesthetic injections

are typically not required because anesthetic is added to the

material during the reconstitution process. The patient is

usually positioned in an upright, seated position as the mate-

rial is injected into the deep dermis. Following the injection,

there is minimal discomfort or bruising. One unique aspect

of Sculptra

injections is the fact that immediately following

the procedure, the treated area looks great. This is some-

what deceptive because as the water and lidocaine used to

mix the material get absorbed, the areas begin to look as if

nothing had been injected. After about the third week, the

body begins to make collagen as wrinkles and creases begin

to fade. With each additional treatment, the improvement

becomes more noticeable.

Average Sculptra

treatments require three or four injec-

tions and last for several years.

When measured on a cost-per-month basis, Sculptra

may

be more cost effective than treatments lasting a few months.

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Facts About Fat Transfer

Autologous fat transplantation was one of the earliest tech-

niques used to erase wrinkles. Under the right circumstances

it is great. I compare it to using a broad paintbrush capable

of treating large areas. Fat transfer allows the physician to

use large amounts of fi ller, something not practical with

small, pre-packaged syringes.

Semi-Permanent & Permanent Fillers

“Permanent fi llers hold great potential for cosmetic derma-

tology. In the future, they may be molded, dissolved, or even

augmented after implantation.”

Fillers engineered to last for years or even decades are pres-

ently in use. Some offer safe and effective treatments that

can be repeated. However, there are not many studies on the

long-term consequences of most of these products, and I use

them cautiously. Despite having FDA approval, I will not use

some of these until I am convinced they are safe (my rule

is that if I would not inject it into my family, I will not use it

on my patients). I am concerned about potential migration

with some of these products. I also have serious reserva-

tions about how they will look as the face continues to age.

Permanent fi llers presently in use or under consideration for

use include Artefi ll

and silicone. The semi-permanent fi ller

that is presently having the most impact in cosmetic derma-

tology is Radiesse

™

ArteFill

ArteFill

is made from polymethylmethacrylate microspheres

(PMMA) suspended in bovine collagen. PMMA is chemically

similar to acrylic. Following injection, the collagen degrades,

leaving behind microspheres as a permanent fi ller. PMMA has

been safely used in dental and orthopedic applications. Its use

Fillers for Facial Rejuvenation

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PALM BEACH PERFECT SKIN

as a cosmetic device has been studied in Europe, Canada, and

the United States. Artefi ll

is implanted into the deep dermis

with a needle and then massaged and molded to the contour

desired. This product is used for the treatment of acne scars

and for correction of creases including the nasolabial folds.

Complications include lumps, infl ammation, granulomas, local-

ized hardening, rashes, and migration of the microspheres.

Although it was approved by an FDA panel, it is presently not

approved for use by the FDA. I intend to observe the results

obtained with this product for a while before I integrate it

into my cosmetic practice.

Radiesse

™

Radiesse

™

(formerly known as Radiance FN

™

) is composed of

calcium hydroxylapatite (CAHA). This material is comprised of

calcium and phosphate, and it forms the scaffolding for bones.

It is highly biocompatible and has been safely and effectively

used for years in non-cosmetic indications. It is approved by

the FDA for craniofacial surgery, and it has been extensively

used in the United States. Radiesse

™

is injected into the deep

dermis in locations such as the nasolabial creases, marionette

lines, chin, and cheekbones. It is not a good product for lip

augmentation or for placement in the crow’s feet, where it has

a tendency to migrate and form granulomas (lumps). At the

present time, several studies are being conducted to deter-

mine the duration of correction obtained with this product

when it is used for cosmetic indications (we are involved with

some of these). My belief is that the product is safe and effec-

tive and that it will provide correction that is durable for at

least one year and perhaps longer.

An injection of Radiesse

™

begins by preparing the area

with alcohol or surgical scrub. The patient is seated upright

or slightly reclined. Anesthesia is obtained with injections

similar to those made by a dentist and then a series of small

injections are made. Following the procedures, some bruis-

ing or swelling may occur, but typically this is minimal.

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Injectable Liquid Silicone

Perfect Skin Hint: Stay away from permanent fi llers such

as silicone unless you are sure that you are pleased with

the way you look with fi llers in your face. Start a soft tissue

augmentation program with an absorbable product to see if

fi llers are right for you.

Silicones are man-made polymers containing silica. They may

exist as solids, gels, or liquids. Liquid silicone has been used

for decades to treat wrinkles and scars. Unfortunately, the

purity and density have been variable and this has resulted

in widely variable results. One attraction of silicone is that

it is inert (when pure) and permanent so corrections by

using it will last forever. Present formulations of silicone are

approved for use inside the eye. They are more pure than

prior products and are more suited for dermal injection. Sili-

cone is experiencing a resurgence of popularity among cos-

metic dermatologists and several respected dermatologists

swear by it. I have had the privilege of authoring an article

on silicone with David Duffy, M.D. and Rhoda Narins, M.D.,

and this experience taught me a great deal about the prod-

uct. When considering silicone injections it is imperative to

make certain that the dermatologist or plastic surgeon has a

great deal of experience. Silicone injections, more than any

other product, are exquisitely technique dependent.

A silicone injection begins with a cleansing of the area

to be treated. Tiny injections of silicone (known as “micro-

droplets”) are injected with small needles. The procedure is

repeated every few weeks, gradually building up the treated

area. Adatosil-5000 and Silikon-1000 are presently available for

ophthalmic usage in the United States. They are being injected

into the skin in an “off label” usage by many physicians with

differing degrees of success. When considering treatment with

silicone, remember that like diamonds, silicone is forever.

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PALM BEACH PERFECT SKIN

The Spectrum of Dermal Fillers

Trade
Names

What Is It
Made From?

How Long
Does It
Last?

FDA
Approval

Post-op

Hyaluronic

Acid

Bio-

engineered

Restylane

Perlane1 pt,
Captique™

Biocompat-
ible substance
found in all liv-
ing organisms

6–12
months
depending
on formu-
lation

Restylane

is FDA
approved;
other forms
are under
investigation;
Captique™
is FDA
approved;
Juvederm

is under
investigation

None; for
extensive
treatments;
up to 48
hours

Hyaluronic

Acid

Animal

Origin

Hylaform

Plus

Biocompat-
ible substance
found in all liv-
ing organisms

4–6
months de-
pending on
formulation

Hylaform

and Hyla-
form

Plus

are FDA
approved

None; for
extensive
treatments;
up to 48
hours

Bovine

Based

Colagen

Zyderm

Zyplast

Derived from
purifi ed bovine
(cow) collagen

2–6
months

FDA
approved

None

Human

Based

Collagen

Cosmo-
Derm

Cosmo-
Plast

Derived from
human
collagen

2–6
months

FDA
approved

None

Calcium

Hydroxly

Apatite

Radiesse™

Calcium Hy-
droxylapatite
–the synthetic
form of
material found
in bone and
teeth

2–4 years

FDA
approved;
off-label
cosmetic use

None

Poly-

L-Lactic

Acid

Sculptra

NewFill

Polylactic
acid, found in
suture material

12–24
months

FDA ap-
proved;
off-label cos-
metic use

None

Injectable

Liquid

Silicone

Adatosil
5000,

Silikon 1000

Liquid inject-
able silicone

Permanent

FDA
approved;
off-label
cosmetic use

None

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CHAPTER

Holding on
by a Thread

“The experience and skill

of the dermatologist or

plastic surgeon using threads

for facial rejuvenation is critical

to achieving a good outcome.”

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PALM BEACH PERFECT SKIN

Sometimes the search for perfect skin takes unusual twists

and turns. One new method for facial rejuvenation involves

the placement of tiny threads under the skin. I have recently

begun to use this innovative technique that literally lifts the

face. Although not as invasive as a traditional face or brow

lift, this procedure is more invasive than fi llers or Botox

Contour Threadlift

™

This procedure provides both lifting and shaping by using

tiny “barbed” threads that resemble porcupine quills. These

threads are inserted into the subcutaneous tissue using a

long needle inserted into tiny incisions in the skin. As the

needle is withdrawn, the barbed threads engage the skin

allowing the dermasurgeon to lift, sculpt, and shape brows,

cheeks, and jowls. The effects of the procedure are immedi-

ate and the risks and recovery time are minimal.

Threads designed to lift the skin come in various forms,

each with its own loyal following. In the United States, the

leader in thread technology is the Contour Thread, devel-

oped by plastic surgeon Dr. Gregory Ruff. The Contour

Thread is FDA approved, and it is used by specially trained

dermatologic surgeons and plastic surgeons.

Who Is a Good Candidate?

Threadlifting is appropriate for patients whose face has

begun to sag but whose skin retains good tone and texture.

In these individuals, threads can lift the face without the cut-

ting required by a traditional facelift. Ideal candidates for this

procedure are typically between 35 and 65.

Who Is Not a Good Candidate?

A threadlift is not appropriate for patients with redundant

skin that needs to be excised. Poor candidates include

patients with unrealistic expectations, uncontrolled medi-

cal illnesses, those who are grossly overweight (with heavy

faces) or those who have excessively thin skin.

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What Areas Can Be Lifted?

This procedure is appropriate for the forehead, cheeks, jowls,

and neck.

How Is the Procedure Performed?

Prior to inserting the threads the areas are cleansed with

surgical cleanser. Some hair from the hairline must be

trimmed to allow for insertion of the threads. Anesthesia

is obtained with injections of local anesthetic, and patients

are awake during the procedure. The procedure begins with

a small incision and insertion of a long, thin needle that

traverses the area to be lifted. The needle is removed away

from the site of insertion and pulled through to engage

the barbs. When lifting the brow, the needle is inserted in

the hairline of the temple and removed at the base of the

eyebrow. As the quills engage the skin, the forehead is lifted

upward. Threads are inserted on each side of the face with

results that are symmetric. Two to four threads may be

used in each area treated. Each area requires about 15–30

minutes. Costs for the procedure vary depending on the

number of threads utilized but average about $500–$700

per thread inserted. An average full face procedure may

require 12 to 16 threads.

What to Expect After the Procedure

Following a thread lift, patients usually experience minimal

discomfort. Most are able to return to work after two days.

Many patients experience minor swelling or bruising that lasts

for about one week. Strenuous exercise should be avoided

for at least one week following the insertion of the threads, as

vigorous motion may cause the threads to move. The insertion

sites must be kept clean with antibiotic ointment applied for

one week after the procedure. It is best for patients to keep

their heads elevated on several pillows when in bed and avoid

resting on the treated areas for at least two weeks. Aspirin

should be avoided for one week after a procedure. Vigorous

Holding on by a Thread

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PALM BEACH PERFECT SKIN

rubbing or washing of the skin may dislodge the threads and

should be avoided for two weeks.

How Long Do the Results Last?

The threads are plastic and theoretically last forever. How-

ever, as the body continues to age wrinkles, and creases will

begin to recur. In addition, the threads will stretch over time

and additional procedures will be required after several

years. After a few years, additional threads can be inserted to

“tweak” the original procedure.

Threadlift can be used in conjunction with other mini-

mally invasive cosmetic procedures, including Sculptra

and

Restylane

, liposuction of the neck and jowls, Botox

, and

radiofrequency skin tightening. At the present time, absorb-

able sutures are being investigated as lifting materials and I

believe that this will offer an exciting opportunity for physi-

cians and patients alike.

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CHAPTER

Tumescent
Liposuction

“Liposuction, when performed

properly, is among the most

gratifying procedures offered

by cosmetic dermatologists.”

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PALM BEACH PERFECT SKIN

Liposuction is the most frequently performed cosmetic surgery

procedure in the United States with approximately 250,000 pro-

cedures performed each year. Despite the popularity of the pro-

cedure, there are many misconceptions regarding the safety and

effi cacy of liposuction, as well as what type of physician should

perform the procedure. The procedure is safe when performed

using local anesthetic, and it has a very high satisfaction rate. The

procedure is not a substitute for weight loss and is a sculpting

process that removes pockets of unwanted fat.

Put simply, liposuction is the removal of fat through a vacuum.

Two basic variations exist and may be classifi ed, for lack of better

terminology, as wet and dry. Wet liposuction refers to the tumes-

cent technique of liposuction, which uses large volumes of dilute

anesthetic to numb the area and minimize the risk of bleeding.

Dry liposuction uses general anesthesia, and is associated with

signifi cantly greater risk than the tumescent technique.

Tumescent liposuction was developed by dermatologist Jeff

Klein, M.D., as a safe and effective alternative to liposuction

involving general anesthesia. After the initial skepticism which

accompanies any signifi cant advance, the dermatologic surgery

community embraced tumescent body sculpting. Dermatologic

surgeons typically perform this procedure with mild or no seda-

tion. To further increase patient safety, they do not typically per-

form liposuction in conjunction with other procedures such as

a tummy tuck or facelift. One other safety feature utilized by der-

matologists is the avoidance of large volume liposuction. These

factors are responsible for the fantastic safety profi le of tumes-

cent liposuction when performed by dermatologic surgeons.

As with any cosmetic procedure, fads come and go. As an

example, a few years ago, ultrasonic liposuction was in high

demand, and patients were led to believe that it would melt

away excess fat. Results obtained from studies of ultrasonic

liposuction demonstrated results that were no better than

those obtained with traditional methods. However, the rate of

complications increased.

At the present time, there is a debate among physicians

regarding who should perform liposuction. Although the dis-

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cussion is veiled in concerns about patient safety, it is really

about money because the safety and effi cacy of the procedure

performed by dermatologists has been well documented.

Despite data to the contrary, plastic surgeons believe that they

are the only physicians qualifi ed to perform the procedure.

Dermatologists point to the data demonstrating better safety

when they do the procedure, and the fact that they pioneered

the tumescent technique. I have seen great results from both

dermatologists and plastic surgeons, and I believe that out-

comes with liposuction depend on the particular physician

rather than the specialty. When considering liposuction, it may

be helpful to speak with patients who have had the procedure

performed by the doctor you are considering. At the very least,

you should know how many procedures a doctor performs

each year and how long he or she has been doing liposuction.

How Safe Is Liposuction?

This question has been asked on numerous occasions, gener-

ally following sensational stories in the media about liposuc-

tion gone awry. The most comprehensive study evaluating

the safety of tumescent liposuction was performed in 2004

(Hanke, William, Cox, Sue Ellen, Kuznets, Naomi & Coleman,

William P. (2004) Tumescent Liposuction Report Performance

Measurement Initiative: National Survey Results

). The fi ndings

of this study demonstrate a remarkable degree of safety and

satisfaction of liposuction performed by a dermatologist. The

overall complication rate was found to be 0.57 percent, and

most of these complications were minor. Major complications

included one instance in which a patient required hospitaliza-

tion. No long-term complications or deaths were reported.

Eighty-four percent of the patients surveyed were very satis-

fi ed with the outcome of their liposuction.

What about the stories reporting deaths from liposuction?

Deaths from liposuction were reviewed in a study evaluat-

ing 19 months in Florida. During this time eight deaths due

Tumescent Liposuction

127

Dermatologic Surgery 30 (7), 967-978. doi: 10.1111/j.1524-4725.2004.)

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PALM BEACH PERFECT SKIN

to liposuction occurred. The common denominator in each

case was general anesthesia (Coldiron, Brett (2002) Offi ce

Surgical Incidents: 19 Months of Florida Data)

. NONE of these

deaths could be attributed to liposuction performed only with

local anesthetic by a dermatologist (this less sensational news

was not reported).

If studies show that liposuction is safe and effective, why

are there so many stories in the news about procedures gone

awry? Simply put, all liposuction procedures, including those

done with general anesthesia, are lumped together despite

the fact that they have totally different safety profi les. Making

matters more confusing is the fact that there are gynecologists,

anesthesiologists, and family practice doctors performing the

procedure with little or no formal training.

Consider the following:

• large volume liposuction has increased risks when compared

with low volume

• the use of general anesthetic increases the risk of the

procedure

• combining liposuction with other procedures such as tummy

tucks or facelifts increases the amount of time for surgery and
simultaneously increases the complication rates

Who Is the Ideal Candidate?

The best candidates for tumescent liposuction are close to their

ideal body weight (within about 20 percent) who need help

getting rid of a few pockets of fat resistant to diet and exercise.

Liposuction is not for patients who are greatly overweight unless

he or she commits to a program of weight loss and exercise. It is

a waste of time, effort, and money to remove between two to fi ve

pounds from someone who will not see any change.

The ideal liposuction patient is between the ages of 20 and

65, with good skin tone. A woman or man with a good fi gure

Dermatologic Surgery 28 (8), 710-713.doi: 10.1046/j.1524-4725.2002

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and disproportionately large love handles, hips, abdomen, or

other part of the body is a great candidate. Patients with one

particular area of fat that does not fi t with the rest of their

body will usually have great results. It is also very important

to have realistic expectations and a good self image before

undergoing this procedure. A thorough understanding of the

procedure is also important for good outcomes.

A liposuction consultation begins with a discussion of

the risks, benefi ts and limitations of the procedure. I do this

at the outset of the discussion to eliminate patients look-

ing for a quick fi x. When I tell people that they can expect

about a 50 percent reduction of any pockets of fat that can

be grabbed, about 50 percent of the people are no longer

interested. I make sure that those who remain are healthy,

are free of hernias (a risk factor), are not pregnant, and do

not have allergies to any of the materials I plan to use. Most

importantly, I try to make sure that the patient and I have

a good rapport. I see my patients frequently following the

procedure, and it is mutually benefi cial to have a positive

relationship for the questions and concerns that arise follow-

ing the procedure. During a consultation, I review the risks,

benefi ts, and limitations of tumescent liposuction. These are

also clearly spelled out in a lengthy consent form. A video of

an actual procedure is available for those patients who wish

to view it (Visit www.palmbeachcosmetic.com).

Inevitably, the fi rst question patients ask is; “will the fat sim-

ply move to another part of the body after liposuction?

” The

answer is no. However, if you consume an unhealthy and fatten-

ing diet, you will put on weight, and the new fat deposits will

settle on your body. A common misconception is that liposuc-

tion predisposes you to put on fat in other areas of your body.

The reality is that if you maintain a stable body weight after

liposuction, your body will not develop new pockets of fat.

My staff discusses fees and scheduling for the procedure.

My fees are based on the number of areas treated, with a

baseline fee for the fi rst area and additional fees for each

new area. Fees for liposuction depend on how many areas

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PALM BEACH PERFECT SKIN

will be treated, the region of the country in which the proce-

dure is performed, the type of facility utilized, and the indi-

vidual physician involved. Typical procedures cost upward of

$5,000 for multiple areas.

“Never shop for a bargain when you are considering liposuc-

tion; choose a doctor who has the experience, personality,

and staff that is right for you.”

The Liposuction Procedure

Prior to the procedure, I take photographs of the areas that will

be treated. Areas to be treated are then cleansed with a surgical

cleanser, and outlines of the fat pockets are marked with a mark-

ing pen. Diluted anesthetic is then slowly injected to numb the

areas. This anesthetic also decreases bleeding. After 15–30 min-

utes small (3–4 mm) cannulae are introduced under the skin and

the fat is gradually removed. The procedure is very quiet, and

most patients watch a movie during the procedure. As I remove

the fat, I pinch the areas to help fi nd any remaining fat. It is not

possible to visualize directly the fat since we use tiny incisions.

At some point in the future, I have no doubt that cameras will be

placed on the tips of the cannulae, enabling direct visualization

of the procedure. The procedure is very gentle when it is per-

formed with the tumescent technique, and patients are generally

able to get up and walk following the procedure.

After the procedure (which typically takes about 15 to 30

minutes per area treated) I look for areas that may need more

attention. When everything looks good, my medical assistants

express excess fl uid and apply dressings to the sites. Some

incisions are sutured while others are left open to drain the

anesthetic material. There is no conclusive evidence that either

of these approaches is superior.

What to Expect After Liposuction

Following the procedure, patients should receive very explicit

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instructions. Supplies should also be provided so you do

not have to run to the store afterward. In my offi ce, printed

instructions are provided during the consultation so that

patients know exactly what to expect. In addition, we pro-

vide a gym bag containing pads, tape, and a body garment

designed for the treated areas.

Liquid anesthetic typically drains for about 24 hours after

the procedure. It is reasonable to resume most normal activi-

ties including work. Vigorous exercise may be resumed after

about one week. Walking is encouraged almost immediately

after the procedure. My patients are routinely surprised by

their lack of discomfort. Most return to work in a day or two.

It is important not to lie down constantly after any proce-

dure, as this will increase the chance of developing blood

clots. Women undergoing liposuction may have irregular

periods which tend to begin earlier than normal.

Results of liposuction are apparent one month after the

procedure. However, the fi nal contour requires between six

and 12 months as the body gradually remodels the treated

areas. Lumps and asymmetry are commonly noted for between

two to 20 weeks but usually disappear after six months. I

recommend massaging the treated areas to speed the healing

process. Massage should be done daily for about six weeks.

Fat Transplantation

The procedure was initially used to disguise spies during

World War I. Its ability to mold and sculpt the face became

a valuable asset during the War, and soon thereafter, it was

introduced for cosmetic use. In the late 1980s, there was a

resurgence of interest in the procedure as dermatologists and

plastic surgeons demonstrated consistent and durable results.

Fat transplantation has seen a renaissance, and many excellent

practitioners in the plastic surgery and dermatologic surgery

communities perform this procedure daily. Newer variations

in technique have rekindled public interest for the procedure.

Synthetic fat substitutes are presently available in Europe and

will be introduced into the United States in the near future.

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PALM BEACH PERFECT SKIN

Fat is one of the most widespread materials used for rejuve-

nation. This stems from its ability to restore signifi cant volume

loss while having no potential for allergic reaction. Fat remains

my fi rst choice for patients who need large amounts of volume

for facial rejuvenation.

The procedure requires several, separate procedures, each

spaced between one and three months apart. Fat is har-

vested from the hips, buttocks, or abdomen using dilute local

anesthetic. After it is washed in saline, it is transferred into

syringes. Some may be frozen for later use while others are

immediately injected into the face or hands. Fat transplantation

has many variations. Some physicians centrifuge the fat while

others remove solid cores of material. I use gentle suction to

remove the fat and wash it with saline prior to either freezing

or implanting.

The Fat Transfer Procedure

I perform fat transplantation in the offi ce rather than the

hospital and begin with a thorough cleansing of the donor and

recipient sites. The site from which fat is removed is anesthe-

tized with dilute anesthetic, and the receiving area is then

injected with standard lidocaine. Fat is removed using small

cannulae especially designed for this procedure. Once cleaned,

the fat is ready for injection or storage.

Results depend on your overall health, whether or not you

smoke, and the method of harvesting and implantation utilized.

It is reasonable to expect 50 percent viability of transplanted

fat after three injection sessions. Of the fat transferred, some

will last for a few months or years. Variations in the viability of

transferred fat are diffi cult to predict and vary not only with

the type of procedure but also from individual to individual.

Mild to moderate swelling and bruising are common after this

procedure. Symptoms that should prompt a call to your physi-

cian include fever, chills, pain at the sites of treatment, shortness

of breath, or lethargy. Although the risk of infection is quite low,

many physicians prescribe antibiotics prophylactically.

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CHAPTER

Eradicating Veins,
Unwanted Hair
& Stretch Marks

“New technology including lasers

and radiofrequency can remove

unwanted hair, stretch marks

and veins.”

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PALM BEACH PERFECT SKIN

Perfect skin may be complicated by unwanted hair, blood

vessels, and stretch marks. Fortunately, new lasers, light

sources, medications, and treatments can eradicate each of

these concerns.

Leg Veins

These unsightly discolorations are one of the most common

causes for visits to a dermatologist. Although I have two dif-

ferent lasers approved to treat blood vessels, I use injections

for treating most leg veins because of the superior outcomes

it offers.

These injections are known as sclerotherapy, and

utilize salt water, glycerin, or a detergent. The materials

are injected into vessels with very small needles. They cause

a low-grade irritation of the vessel wall and this causes

them to become infl amed and seal. No matter which agent

is selected, multiple treatments are needed. Typical treat-

ments require between three and six visits spaced about a

month apart.

My preferred injection solution is saline because it is safe

and effective. Unfortunately, it is also uncomfortable. When

Aethoxysclerol (used in Europe and Canada) is approved by

the FDA, this may offer better results with less discomfort.

Many dermatologists use Sotradechol, which is approved for

use in the United States and is less painful. However, it can

cause hyperpigmentation and allergic reactions, so therefore

I use it cautiously. One common side effect with any injec-

tion is blushing. This occurs when small vessels multiply and

the area looks worse. The treatment for blushing is to either

continue injections or use a laser to treat the area. Either

way, it is important to continue treatment in order to avoid

legs that look worse than when the treatments began.

If you plan to undergo sclerotherapy, you should not be

pregnant or nursing or have a history of blood clots. Before

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beginning sclerotherapy, budget the time, money, and com-

mitment to come to an offi ce for two to ten visits. If you are

taking estrogens (such as oral contraceptives), which can

stimulate growth of blood vessels, sclerotherapy may not be

maximally effective. Although discontinuation of birth con-

trol pills is not warranted, some extra visits may be needed

to get the desired results. One additional consideration

for women who take oral contraceptives and smoke is the

increased risk of developing blood clots.

Depending on state regulations, sclerotherapy may be

performed by a physician, nurse or physician’s assistant. As

with any procedure, the outcome depends on the skill of the

injector so make sure that the person treating you is quali-

fi ed and experienced.

To date, lasers have not lived up to their promise for

treating leg veins because they require such high energy

that scarring, hyperpigmentation (increased pigment), and

hypopigmentation (decreased pigmentation) may result from

treatment. Lasers currently being developed may be able to

treat vessels with a low risk of scarring.

The most exciting development for erasing leg veins is

the use of radiofrequency waves to seal vessel walls. Using

ultrasound guidance, dermatologists, vascular surgeons, and

radiologists introduce small catheters into blood vessels to

heat them. Dilute lidocaine is administered as an anesthetic.

Recovery time for this procedure is minimal, and my patients

that have had it are thrilled with the results.

Hair Reduction Strategies

“Laser hair reduction remains one of the most popular cos-

metic dermatology procedures.”

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PALM BEACH PERFECT SKIN

Since humans fi rst stood upright they have been trying to

eliminate hair on certain parts of their body while attempting

to grow hair on others. Hair desirability is subject to a variety

of cultural and personal preferences, but the overall demand

for reducing unwanted hair is huge. According to Medical

Insight, the market for laser hair removal has now exceeded

$2 billion per year. Waxing accounts for another $3.5 billion

dollars spent. More than 70 percent of women in the United

States use one or more methods to remove unwanted hair.

The most common areas for hair reduction in women

are the upper lip, chin, cheeks, legs, armpits, and bikini area.

Many factors, including genetics and hormones, control hair

density in these areas. Some ethnic groups have increased

hair density above the lip. Diseases such as polycystic ovary

disease and certain medications may also stimulate excessive

hair growth in distinctly unfeminine patterns.

To understand how to get rid of hair, it is important to

understand how hair grows. Hair growth is cyclical and

begins with the growth cycle known as anagen. Anagen

may last for two to seven years (the duration of this cycle

determines the maximum hair length). Following anagen is

catagen, a transition cycle that lasts for about 10 to 14 days

Telogen (the resting phase) follows catagen and lasts from

two to four months. According to Barnhill et al, there are

about 100,000 hairs on the human head. On an average day,

about 100 of these are shed (and hopefully replaced).

Hair growth and hair reduction depend on the follicular

stem cell, which is responsible for generating hair. This stem

cell was discovered by George Cotsarelis, M.D., who I believe

will eventually discover how to switch hair growth on and

off at will.

Shaving is the most basic method of hair removal. Shaving

works no matter which part of the cycle the hair is in, and

Barnhill R, Textbook of Dermatopathology, p201, 1998 McGraw Hill

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unlike lasers, it does not discriminate based on the color

of the hair. The major disadvantages of shaving are that it is

time consuming—my sister estimates that using the laser

instead of shaving saves her about four to six hours of time

per month—and expensive, if you add up all the material

used for blades, creams, and band aids. Presently, shaving is

the most popular method of hair removal. Complications

from shaving are rare except for darker skin which has a

tendency to develop “shaving bumps” (keloids).

Tweezing is another simple and inexpensive way to

remove hair. This process may be acceptable for a small area

such as the lip but it obviously is not practical for larger

areas, and suggesting it for the bikini may result in bodily

harm. Tweezed areas remain free of hair for a few weeks.

Potential complications from tweezing are scarring and

infection. Avoid tweezing nose hairs; infections in this area

are dangerous and may require intravenous antibiotics.

Depilatories are chemicals that break up the structure

of the hair shaft, causing the hair to fall out. These creams

and lotions (such as Nair) provide relief from hair for two to

six weeks. The downside to these products is that they may

cause skin irritation.

Waxing remains one of the more popular methods of

controlling hair growth. Application of either hot or cold

wax to areas of unwanted hair is followed by removal of the

wax and the hair attached to it. In addition to discomfort,

occasional infections of the hair follicle irritation may follow

this treatment.

Sugaring is similar to waxing except that a sugar paste is

used instead of wax. It pulls out the hair shaft at the level of

the root and lasts for about one to two months.

Vaniqa is a topical medication approved for the reduction

of hair. This prescription drug inhibits hair growth to some

degree, but it is not effective enough for most women to

consider it worthwhile. It has been around for several

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PALM BEACH PERFECT SKIN

years and has never really caught on. Future versions will

inhibit hair growth more effectively and probably be

more popular.

The last hair reduction strategy we will consider is

electrolysis, which uses tiny needles inserted into the root

sheath of each hair. Electric current is applied to the needle,

creating a chemical reaction that releases hydrogen per-

oxide which kills the hair follicle. This procedure is user

dependent ,and the risks and results depend on the skill of

the person performing the procedure. When poorly done,

the procedure may result in scarring, infection, and pigment

irregularity. Electrolysis is time consuming and expensive

when applied to large areas, and these limitations preclude

widespread use.

HAIR REMOVAL METHODS

Method

How It

Works

What It

Treats

Duration of

Results

Side

Effects

Shaving

Sharp-edged
cutting instru-
ment (razor) or
electric device
with a vibrat-
ing or rotating
cutter (shaver)
slices off hair

Beards,
mustaches,
legs, underarms

1–3 days

Minor cuts,
irritation,
ingrown hairs

Tweezing

Tweezers grasp
and remove hair
from its root

Eyebrows, facial
hair

2–8 weeks

Momentary
pain, infected
follicles, skin
discoloration,
ingrown hairs,
scarring

Chemical
Depilatories

Chemicals in
these creams or
lotions dissolve
hair shafts

Some products
for legs only;
others for
underarms,
face, bikini line

Up to 2 weeks

Swollen, itchy,
reddened skin

Waxing

Hot or cold wax
adheres to

Legs, under-
arms, bikini line,

2–8 weeks

Momentary
pain, irritation,

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Eradicating Veins, Unwanted Hair & Stretch Marks

139

Method

How It

Works

What It

Treats

Duration of

Results

Side

Effects

Waxing

hair, removing
hair shafts from
roots when
peeled off

eyebrows, chin,
upper lip, chest,
back

burns from hot
wax, infected
follicles, skin
discoloration,
scarring, allergic
reactions

Sugaring

Sugar paste
adheres to hair,
removing hair
shafts from
roots when
pulled off

Eyebrows,
upper lip, un-
derarms, legs,
arms, abdomen,
bikini line

4–6 weeks

Stinging,
redness

Mechanical
Epilators

Electric device
with rubber
roller or coiled
spring catches
hair and pulls it
from roots.

Less sensitive
areas, espe-
cially legs

Up to 1 week

Momentary
pain, irritation,
missed hair

Efl ornithine
(Vaniqa)

Chemical in this
prescription
cream inhibits
hair growth

Only approved
for slowing
down exces-
sive facial
hair growth in
women

Permanent
with continued
use; takes 1–2
months to see
initial results;
can be used
with other
hair removal
methods

Acne, irritation,
ingrown hairs

Electrolysis

Electrifi ed
needle destroys
follicles either
by causing
a chemical
reaction or by
burning them

Lips, chin,
eyebrows,
neck, ears,
shoulders, bikini
line, abdomen,
breasts, arms,
underarms

Usually perma-
nent after sev-
eral treatments,
but depends
on method and
operator

Swelling,
redness,
permanent skin
discoloration,
pain and scar-
ring (particularly
with home kits);
may interfere
with pacemaker
function

Laser

Laser beam tar-
gets dark pig-
ment (melanin)
in hair follicle,
destroying fol-
licle with heat

Face, upper
lip, neck,
chest, breasts,
underarms,
back, abdomen,
bikini line, legs

Usually
permanent
after
several
treatments

Swelling,
redness,
burning pain,
permanent skin
discoloration

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PALM BEACH PERFECT SKIN

Laser Hair Removal

Laser hair removal is a safe, effective way to permanently

get rid of unwanted hair. This is technically called reduction

rather than removal, because it reduces rather than rids the

hair in a given area. Hair reduction is used to mean an 80

percent reduction of the hair density.

The principle underlying laser hair removal is known

as selective thermolysis, and it was fi rst proposed by Rox

Anderson, M.D. Selective photothermolysis refers to a light

(or laser) that can target one color or tissue without affect-

ing another. When applied to hair reduction, lasers or strong

lights target pigment at the base of the follicle to destroy the

matrix stem cells. Present lasers work well when used on

light skin and dark hair. This combination allows energy from

the laser to pass through the skin and get absorbed by the

dark hair. When used on dark skin, the energy gets absorbed

by the skin and may cause loss of pigment or scarring with-

out affecting the hairs.

Many different lasers can be used to treat unwanted hair.

They vary in their use of a cooling device (used to increase

comfort and minimize complications) as well as in the

wavelength used. When considering laser hair removal, learn

about the type of machine being used and whether or not a

cooling device is employed. Devices that chill the skin cost

more than those that do not since they require continu-

ous supply of coolant. I have used the Candela Gentlase for

years, and I have been impressed with its safety, effi cacy, and

patient satisfaction. Recently I have begun to use the Palo-

mar Starlux system and it has performed quite well.

“Beware of clinics and salons offering hair removal lasers

by untrained staff without medical supervision. Find out if

there is a true Medical Director on site and if he or she is a

dermatologist or plastic surgeon.”

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When considering laser hair removal, do not shop for a

“deal”—these tend to be expensive when you factor in the

cost of complications. Choose the device and physician’s

offi ce that has the experience and knowledge to treat you

safely and effectively. As with any cosmetic procedure, be

wary of the gynecologist or family practice doctor who

dabbles in procedures for which they are not trained. One

trend spreading across the United States is the use of “medi-

cal directors” to supervise laser clinics. These may be retired

physicians, ones who have lost licenses in other states or

doctors renting out their licenses. Complications are more

frequent in this scenario, and these facilities are the least

prepared to handle them.

The Laser Hair Removal Procedure

A light beam about the size of a dime is used to treat large

areas in minimal time. Treating a face may take 10 to 15

minutes while an average sized back takes about 30 to 45

minutes. Eye goggles are worn whenever a laser is used to

protect the eyes from light bouncing off metal objects. Even

in the best practices, laser treatments have some risk, and it

is important to understand the risks of the procedure before

having it. Typical treatment sessions require four to six visits

spaced about a month apart.

Prior to a laser hair removal procedure, one should not

pluck or tweeze hairs for about a month. Chemical depilato-

ries and waxing should also be avoided for the same amount

of time.

The sensation of laser hair removal has been compared

to a rubber band snapping. A hand or foot trigger is used to

control the laser. Each patient has individualized settings

that depend on his or her skin color, hair color, and degree

of sun exposure. Cryogen (a freezing spray) may be used to

maintain patient comfort.

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PALM BEACH PERFECT SKIN

LASER HAIR REMOVAL IN A NUTSHELL

• Light is used to heat the base of the hair follicle

• Treatments require several sessions spaced about a

month apart

• The best candidates have light skin and dark hair

• Risks include scarring, infection, and increased or decreased

pigment of the skin

• The procedure may be performed by a physician, nurse,

physician assistant, or by a totally untrained technician,
depending on state regulations

• Laser hair removal centers are proliferating and many offer

skincare. Most employ physicians with no dermatology or
plastic surgery training

If you are considering laser hair removal, you should

minimize your sun exposure for at least one month prior.

This will let the skin become as light as possible allowing

the laser to pass through it without being absorbed. Follow-

ing the procedure, it is important to minimize sun exposure

to decrease the chances of pigment changes. Sun exposure

tends to be a particular problem during the summer (when

people typically want the procedure).

Various lasers may be used for hair reduction. One of the

fi rst was the ruby, which had a tendency to scar and was

replaced by lasers using alexandrite. Alexandrite lasers have

a wavelength (color) of 755 nm which is absorbed by pig-

ment at the base of the hair follicle. Newer devices utilize

intense pulsed light, and unlike lasers, they are able to treat

lightly colored hair. I have been using the Starlux IPL system

for hair reduction and have been impressed with the results.

Complications from laser hair reduction are infrequent

and occur in less than fi ve percent of people treated. The

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most common problems are changes in pigment (either

increased pigment of decreased pigment). Increased pigment

may be treated with medications such as Triluma which con-

tains cortisone, bleaching medication, and tretinoin (Retin-

). Decreased pigment usually resolves spontaneously after

a few months. In rare instances, the decreased pigment is

due to permanent loss of the pigment cells and this may

result in permanent depigmentation.

Future directions for laser hair reduction may involve the

introduction of medications or pigments that are selectively

absorbed by the hair stem cells. These cells could then be

targeted by special lasers. As lasers get more selective, the

procedure will get increasingly better.

Improving Stretch Marks

Stretch marks (striae) are caused by changes of collagen and

elastic fi bers. These changes tend to occur following preg-

nancy, weight loss, or exposure of the skin to excess hor-

mones. Although they begin as red or purple stripes, most

stretch marks end up as porcelain colored streaks. Common

areas for striae include the abdomen, thighs, hips, breasts,

upper arms, and lower back.

A great deal of time and money are invested in treating

stretch marks. Treating striae while they are red or purple

can be accomplished with a pulse dye laser. Once the lesions

have turned beige, there is less that can be done. Micro-

dermabrasion, Retin-A

, Intense Pulsed Light, and injections

of fi llers are used on older, pale stretch marks with varying

degrees of success. Glycolic acid products and green tea

products are also helpful in minimizing the appearance of

stretch marks.

Treatments presently being developed include lasers that

lighten and repigment stretch marks. I anticipate that these

will be the fi rst truly effective treatment available.

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PALM BEACH PERFECT SKIN

If you develop stretch marks without an obvious rea-

son you should consult your dermatologist. Rare hormone

abnormalities can cause them, and this may be detected with

simple blood tests.

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The Structure of the Skin & How This Changes with Aging

145

CHAPTER

Advances in
the Diagnosis &
Treatment of
Skin Cancers

“Skin cancer is the most common

cancer in the United States. When

detected and treated early, the rate

of cure is almost 100 percent.”

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Detection and treatment of skin cancer has been one of

the most signifi cant advances in dermatologic surgery in

the past decade. Public awareness regarding skin cancer

has increased due to programs sponsored by the American

Academy of Dermatology and the American Society for

Dermatologic Surgery. Many of my patients come in with a

mole or other growth that has changed. These people notice

a change in their skin, and if they are not restricted from

doing so by managed care, they come in almost immediately.

Unfortunately, I also encounter patients who ignore their

symptoms, do not recognize that something is wrong, or are

told by an ill-informed healthcare provider that watchful

waiting (rather than a biopsy) is appropriate. One common

denominator for delayed diagnosis or treatment of skin

cancer is skincare received from non-dermatologists who

tend not to recognize the cancer or, if they do, do not treat it

appropriately.

An average skin cancer patient comes to me with a “spot”

that is changing. Sometimes it is “a bump that will not heal”,

“a mole that changed color” or “a sore that is bleeding.” Other

times it is a mole that is growing, bleeding, or itching (this

signals that the immune system is trying to kill the lesion).

For whatever reason, I see a fair number of people who

bang their legs on a car door and later develop a skin cancer

called keratoacanthoma at that site.

When evaluating a lesion, I sometimes use a device

known as a dermatoscope to better visualize it. This device

provides polarized light and magnifi cation which enables

me to see deep into the skin. If the lesion is suspicious, I

perform a biopsy (since these tend not to be planned, we

usually run a little behind schedule). During a skin biopsy,

a small piece of skin (typically smaller than a pencil eraser)

is removed. The procedure uses local anesthetic and takes

a few minutes. The information obtained from the biopsy

allows me to decide whether skin cancer surgery is indi-

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cated. Interpreting skin biopsies is an art form that depends

on the skill of the person who looks at the slide. When I am

able to do so, I personally evaluate my patients’ biopsies, or I

rely on another dermatopathologist to interpret the biopsy.

You should always consider several issues for any

biopsy including:

• Is the physician reading your biopsy a board certifi ed derma-

topathologist? Unfortunately, there is no law mandating that
the person evaluating your slide must be trained to do so.

• Would your dermatologist trust this same person to look at his

or her own skin biopsy?

SKIN CANCER DETECTION HINT

As with Voting in Chicago, go early, go often

Anything that changes size, shape, color, or begins to itch
should be seen by a board certifi ed dermatologist.

Early Detection

The best strategy for beating skin cancer is early detection

and treatment. Several dermatology organizations, including

the American Academy of Dermatology and the American

Society for Dermatologic Surgery, recommend monthly skin

self exams and annual visits to your dermatologist. During a

self exam, you should monitor your entire body for changes

in the size, shape, and color of any spots. When you are not

certain about a lesion, visit your dermatologist to see if it

needs a biopsy. During a skin cancer screening, do not be

too bashful to undress completely. Ask your dermatologist

about any spots or marks that concern you and remember

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PALM BEACH PERFECT SKIN

that a biopsy is always a good way to get an answer.

Many dermatologists believe that sun exposure is associ-

ated with the most common types of skin cancer. Prevailing

wisdom says that most damage occurs during early years,

and that sunburns are much more damaging than moder-

ate exposure. Common skin cancers include basal cell

carcinoma, squamous cell carcinoma, and melanoma. These

will be discussed at length in the following section. A brief

discussion is presented here for purposes of discussing treat-

ments. Of all types of skin cancer, basal cell carcinoma is the

most common. One million of these cancers will be diag-

nosed in the United States this year. Fortunately, they tend

to grow slowly and remain localized. They frequently appear

on sun-exposed parts of the body. Common appearances of a

basal cell include a fl eshy bump with a pearly surface, a scar-

like lesion or a bump that bleeds.

A more severe but less frequent type of skin cancer is

known as squamous cell carcinoma. It frequently appears as

a scaly, red patch or nodule that grows. Common locations

include the nose, ears, hands, and scalp (especially in men

who have lost their hair).

Malignant melanoma is the most serious type of common

skin cancer. Typically, it appears as a mole that changes size,

bleeds, or begins to itch. Most melanomas are asymmetric

due to cells growing at different rates. Many have an irregu-

lar border, are more than one color, and have a diameter of

more than 5 mm. However, not every melanoma follows the

rules, and I have seen several melanomas that had no color;

I would have missed them had the patient not told me they

were changing.

If you have a mole that is changing or itching, ask your

dermatologist to look at it. If he or she is suspicious, ask for a

biopsy. Early detection and prompt intervention by a derma-

tologist, plastic surgeon, or general surgeon remain the best

treatment for melanoma.

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The three most frequent types of skin cancer are mela-

noma, basal cell carcinoma and squamous cell carcinoma.

Actinic keratoses are considered the precursor to squamous

cell carcinoma.

Actinic Keratoses

(Photo Gallery Page 1) Actinic keratoses are considered

precancerous lesions which, if left untreated, can become

squamous cell carcinomas. Actinic keratoses are small, scaly

lesions typically found in sun exposed areas. These lesions

tend to form in groups, and it is not uncommon to fi nd 10 or

15 on the backs of the hands or top of the scalp.

Origins of Actinic Keratoses

Actinic keratoses arise most commonly in sun-exposed

areas. It is believed that the ultraviolet radiation from the

sun causes damage to the skin cells. Once the damaged cells

proliferate, they form scaly bumps known as actinic kerato-

ses. Under the microscope, actinic keratoses appear to be

mini-squamous cell carcinomas. Once again, the importance

of protecting your skin from sun damage cannot be empha-

sized strongly enough.

Symptoms of Actinic Keratoses

“Golfers, tennis players, equestrians, and water sports

enthusiasts will frequently fi nd these lesions on the backs

of their hands.”

Actinic keratoses look and feel like scaly or rough patches.

Those most commonly affected have skin types that evolved

from northern latitude climates; they have fair skin, light hair,

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PALM BEACH PERFECT SKIN

and light eyes. The lesions vary in color from beige to red to

pink. Patients often complain of itching or irritation at the

site of an actinic keratosis. Many patients tell me that after

sun exposure they notice a small area that looks different or

feels irritated. During a skin examination, I can sometimes

discern these lesions by touch rather than sight, and my skin

examination often includes touching the nose or ears to

feel for rough skin. Another area that is frequently affected

by actinic keratoses is the lower lip. In this area, the lip will

become rough, and people typically try to use lip balm to

help a spot heal. These lesions need to be treated because

when they evolve into squamous cell carcinomas, they can

be aggressive. The differences between actinic keratoses and

squamous cell carcinomas are frequently subtle, one reason

why only a board certifi ed dermatologist with the proper

training should care for your skin.

Types of Actinic Keratoses

Some actinic keratoses form thick growths and are referred

to as hyperkeratotic actinic keratoses. Others may become

eroded and thin. When an actinic keratosis is located on the

lip, it is referred to as actinic cheilitis.

Treatment of Actinic Keratoses

Treatment of actinic keratoses is varied and changing all the

time. The simplest treatment involves the application of liquid

nitrogen using a sprayer or applicator at the site. There is

typically some blistering which removes the damaged cells,

allowing new skin to replace it. When there are numerous

actinic keratoses, I frequently use a more global approach and

try to fi x the entire area. This involves using one of a variety of

creams that causes the precancerous cells to be replaced. The

most common topical treatment for actinic keratoses involves

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application of a topical chemotherapy know as 5 fl uorouracil.

This ingredient in found in Effudex, Carac, and a few other

medications. It is applied once or twice daily for about 30

days or until the skin looks like hamburger. Although it does

a great job of fi xing the skin, the unsightly appearance and

discomfort are problematic for most patients.

In an effort to fi nd a gentler treatment, a cream called

Solaraze was developed. It uses a topical form of a non-steroi-

dal anti-infl ammatory agent that causes the precancerous cells

to remodel. Aldara is another topical medication that works by

stimulating the immune system to kill the precancerous cells.

Other treatments include photodynamic therapy using

aminolevulinic acid and a light source to kill the cells. Novel

therapies for actinic keratoses are presently being developed.

Basal Cell Carcinoma

Basal cell carcinoma arises in the basal (bottom) cell layer of

the skin. The incidence of basal cell carcinoma skin cancers

has increased over the past few decades, and the rate of

incidence in women in particular has increased. The average

age of onset has also steadily decreased. More women have

basal cell carcinoma than in the past; yet men still outnum-

ber them greatly.

Origins of Basal Cell Carcinoma

Chronic exposure to sunlight is a major contributing factor for

all basal cell carcinomas. It is not a coincidence that they tend

to occur most frequently on the face, ears, neck, scalp, shoul-

ders, and back. Basal cell carcinoma can masquerade as acne

bumps, eczema lesions, or scars. I recommend that you look

at your skin on a monthly basis and notice any changes that

occur. In addition, I recommend yearly total body skin exams

(more frequently if there are increased risks for skin cancer).

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SYMPTOMS OF BASAL CELL CARCINOMA

Some telling signs that a spot on your skin might be a

basal cell carcinoma include:

• Open Sore that bleeds, oozes, or crusts and remains open

for three or more weeks. A persistent, non-healing sore is a
very common sign of an early basal cell carcinoma.

• Reddish Patch or irritated area, frequently occurring on the

chest, shoulders, arms, or legs. Sometimes the patch crusts.
It may also itch or hurt. At other times, it persists with no
noticeable discomfort.

• Shiny Bump or nodule that is pearly or translucent and is

often pink, red, or white. The bump can also be tan, black, or
brown, especially in dark-haired people, and can be confused
with a mole.

• Pink Growth with a slightly elevated rolled border and a

crusted indentation in the center. As the growth slowly en-
larges, tiny blood vessels may develop on the surface.

• Scar-Like Area that is white, yellow, or waxy, and often has

poorly defi ned borders. The skin itself appears shiny and taut.
Although a less frequent sign, it can indicate the presence of
an aggressive tumor.

Types of Basal Cell Carcinoma

Nodular Basal Cells—Under the microscope, these look

like a ball of deep blue cells. Sometimes, when I look at the

slides, I can see that the biopsy has removed most or all of a

nodular basal cell carcinoma, and my treatment of the lesion

will be much more conservative. These are relatively slow

growing and non-invasive.

Infi ltrative Basal Cell Carcinoma—These lesions look like

an advancing army under the microscope, and I treat them

more aggressively, usually with Mohs surgery when they are

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on the face. They may dissect into the deeper planes of the

skin and recur. Although they do not normally spread, they

can do so in rare instances.

Superfi cial Basal Cell Carcinoma—Superfi cial lesions are

barely getting started and are small foci in the base of the

epidermis. Depending on their size and location, they may

be treated with excision, freezing, electrodessication, and

curettage or with topical Aldara.

Pigmented Basal Cell Carcinoma—These look like shiny

brown or black bumps and are frequently mistaken clinically

for melanoma because of their color and growth pattern.

They are treated based on their pattern of growth.

Treatment of Basal Cell Carcinoma

Treatment depends on the type of basal cell carcinoma, the

depth to which it has penetrated, the location of the lesion,

the size of the lesion, and a variety of other factors includ-

ing the experience of the dermatologist involved in the care.

Most basal cell carcinomas are excised and sutured closed. If

they occur on the face, I usually treat them with Mohs sur-

gery to provide the highest cure rate possible. If the lesion

is on the trunk or extremities and appears to be almost gone

under the microscope, I will curette the lesion out. In rare

instances, I will treat the lesions with Aldara, cryosurgery, or

radiation (usually in patients who are too old to have surgery

or for lesions that are superfi cial in nature).

Squamous Cell Carcinoma

Squamous cell carcinoma is the second most common skin

cancer. It affects more than 200,000 Americans each year. It

arises from the middle layers of the epidermis and occurs

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on all areas of the body, including the lips and nails. It is

most frequently seen in areas that have been exposed to

the sun. Squamous cell carcinomas vary in their behavior,

and the aggressive subtypes can metastasize with fatal

outcomes.

Origins of Squamous Cell Carcinoma

Chronic exposure to sunlight is associated with increased

risks of squamous cell carcinoma. As is the case with basal

cells, these tumors appear most frequently on the face, neck,

scalp, hands, shoulders, arms, and back. The rims of the ear

and the lower lip are especially vulnerable. Burns, immune

suppression (for example, the use of steroids or drugs for

organ transplantation) scars, long-standing sores, radiation,

and certain chemicals (such as arsenic and petroleum

by-products) increase the incidence of squamous cell

carcinoma.

Symptoms of Squamous Cell Carcinoma

Squamous cell carcinomas typically appear as scaly bumps

that grow or bleed. They may arise among a fi eld of precan-

cerous growths known as actinic keratoses. Sometimes, they

grow rapidly and are painful (the keratoacanthoma subtype),

and sometimes they smolder.

Types of Squamous Cell Carcinoma

The least invasive lesion is called an in situ lesion. It is lim-

ited to the epidermal layers and does not breach the base-

ment membrane so it is contained. Invasive squamous cell

carcinomas vary in the degree of differentiation—the more

differentiated, the more they look like normal skin cells. Less

differentiation means that the cells are very unsightly under

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the microscope, and they neither appear nor behave like

normal skin cells. The keratoacanthoma type of squamous

cell carcinomas tends to grow rapidly (over the span of a

few weeks) but tends to behave well with few incidences of

spreading.

Treatment of Squamous Cell Carcinoma

Treatment of these types of skin cancers is primarily surgical

and utilizes the modalities mentioned above. Other treat-

ments are available especially for in situ lesions which may

be treated with Aldara, 5 fl uorouracil, photodynamic therapy,

radiation, or cryotherapy. The appropriate type of treatment

depends on the type of squamous cell, the location of the

lesion, and the pathologic pattern.

Melanoma

Melanoma is the most deadly form of skin cancer. How-

ever, if diagnosed and removed while in its early stages, it is

almost 100 percent curable. Unfortunately, once it spreads

it is diffi cult to treat and is frequently deadly. Melanoma has

increased more rapidly than any other form of cancer during

the past decade, with more than 51,000 new cases reported

in the United States each year.

The Origin of Melanoma

The cells that give rise to melanoma are known as melano-

cytes. These cells produce melanin, the pigment responsible

for tanning and producing the color of the skin, hair, and

eyes. Typically, melanocytes occupy one out of every eight

cells of the basement membrane of the skin epidermis. When

they proliferate, they may produce freckles or moles. If they

become malignant, they produce melanomas.

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Symptoms of Melanoma

Melanomas may have a myriad of possible appearances

ranging from an irregularly colored lesion to an unremark-

able beige spot. In general, a pigmented spot that is changing

should be considered a potential melanoma and be evalu-

ated by a dermatologist.

MELANOMA DETECTION USES THE “ABCD” RULE

Lesions that are Asymmetric, have Border irregularity, Color
variation (two or more colors), and Diameter equal to or greater
than 6 mm are considered to be suspicious.

While these guidelines are valuable, there are always

exceptions. I have removed several melanomas that were 4

mm or smaller within the past year. For this reason, when

someone tells me that a mole is itching or changing, I usually

biopsy it. Recently, I have begun to use a new type of derma-

toscope that helps to identify early melanomas.

FOUR BASIC MELANOMA TYPES

There are four basic types of melanoma. Each has a
similar prognosis for a given depth of invasion:

1. Superfi cial spreading melanoma is the most common and

accounts for about 70 percent of all cases. This melanoma
travels along the top layer of the skin horizontally before go-
ing vertical where it has access to blood vessels. Superfi cial
spreading melanoma is detected by its irregular borders and
color. This type of melanoma may be seen anywhere on the
body but is most frequently found on the trunk or backs of
men, and on the legs and backs of women.

2. Lentigo maligna is usually seen in fair skinned people with

lots of sun damage. A typical patient will say that a brown
spot has been present for years, has been slowly growing,
and that it has been ignored by other physicians. Usually,
these large brown or black patches are on the face and ears.
These tend to grow slowly and remain superfi cial for long
periods of time.

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3. Acral lentiginous melanoma occurs on the hands, feet,

or nails. They are diffi cult to diagnose and may require a
nail biopsy, so there is often a delay in fi nding them. Most
patients who have discolored nails have a history of drop-
ping something on the nail to injure it. However, some will
come in with a brown or black streak in the nail and a cuticle
that is discolored. It is the cuticle discoloration that usually
mandates a biopsy. Interestingly, this type of melanoma is the
most common melanoma in African-Americans and Asians
and the least common among Caucasians.

4. Nodular melanoma is invasive at an early stage and usually

begins as a black, blue, or pink bump. This aggressive type
of melanoma accounts for 10 to 15 percent of cases.

Treating Melanoma

The treatment of melanoma is surgical. In recent years,

the recommended margins have changed, but the basic

approach has not. If a lesion is not cured with surgery, the

survival rate is poor.

Non-Surgical Treatments
for Skin Cancer

“Until recently, skin cancer meant surgery. Now, creams and

light sources can treat skin cancer without cutting. If you

have skin cancer, you should fi nd out if these treatments

are appropriate for you.”

Today, treatment for early skin cancers may consist of apply-

ing a cream to the lesion. New treatments harness the body’s

immune system to avoid cutting.

The fi rst product in this class of drugs is Aldara (3M). This

drug may be used to treat precancerous growths or actinic

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keratoses, basal cell carcinomas, early squamous cell carcino-

mas, and in some cases, melanomas. Clinical trials are being

conducted on the next generation of topical medications,

and these appear to be more effective than those pres-

ently on the market. Aldara and similar compounds work by

stimulating the body to produce interferon (the “on” switch

for the immune system). Once this occurs, the body sees the

cancer cells as foreign and tries to kill them. The immune

response produces irritation and redness at the treatment

sites. Some patients develop fevers as a result of the inter-

feron made by their bodies. Aldara treatment consists of

applying medication daily or every other day, for a period of

several days to several months. There are no defi nite rules

for how long to use this treatment, and each dermatologist

bases his or her regimen on the appearance of the skin as it

undergoes treatment. When I treat a skin cancer on the face,

I follow the patient closely and may repeat the skin biopsy

at the conclusion of the treatment to determine whether the

cancer is gone.

Another non-surgical skin cancer treatment is photody-

namic therapy. This treatment uses a dye known as aminolev-

ulinic acid to make the skin susceptible to light. The dye is

painted onto the skin and allowed to incubate from several

minutes to several hours. Then a bright light or laser is used

to activate the molecule. Photodynamic therapy is used for

early squamous cell carcinomas and basal cell carcinomas. It

is not presently used for melanomas.

Surgical Approaches to Skin Cancer

“Surgical removal of skin cancers permits an evaluation

of the margins of the specimen, which enables the derma-

tologist to determine whether the skin cancer has been

completely removed.”

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The Structure of the Skin & How This Changes with Aging

159

Until dermatology became a surgical specialty, the treatment

of skin cancer was done by plastic surgeons. However, as der-

matology has become surgical in nature, most skin cancers are

treated by dermatologists. Cutting out skin cancers remains

the treatment of choice for the vast majority of skin cancers

diagnosed in the United States. There are many different

surgical techniques to treat skin cancer, and we will review

the most important ones. Excisional surgery, electrodessica-

tion and curettage, and Mohs surgery are the most frequent

modalities for treating cancer.

Excisional Surgery

This refers to excising (cutting out with a scalpel) a lesion,

and then suturing the defect closed. A dermatopathologist

or pathologist evaluates the edges of the tissue removed to

determine whether the margins of the specimen are free of

cancer. Excisional surgery is performed in a dermatologist’s

offi ce using local anesthesia. A typical procedure takes

about 15 to 30 minutes. Common cancers treated with exci-

sions include: basal cell carcinoma, squamous cell carci-

noma, and melanoma.

Electrodessication and Curettage

This method uses a curette (a rounded metal object with a

sharp edge) to scrape out the skin cancer. Electrical current

is then used to burn (electrodessicate) the base of the lesion.

This process is repeated three times to obtain a margin

around the skin cancer. Older dermatologists believe that

they can feel the difference between normal skin and skin

cancer. I am not a big believer in this ability and prefer to

have a pathologist examine the margins for me. I use elec-

trodessication and curettage in my practice for very early

skin cancers or skin cancers with very indolent features.

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Warning: Mohs surgery is only performed by dermatolo-

gists. Some dermatologists complete training after their

residency in dermatology. Others learn the procedure

during residency and take courses to supplement their

training. The skill of the dermatologist performing Mohs

may be quite variable. At the current time, there are no

regulations as to who may or may not perform this type

of surgery.

Mohs Surgery

Mohs surgery utilizes slides prepared while the patient

is in the offi ce to evaluate the margins of a skin cancer

specimen. It is performed to minimize the amount of tissue

removed from cosmetically important areas such as the face.

By defi nition, the surgeon also functions as the pathologist,

and it is his or her responsibility to determine when the

cancer is entirely removed. Mohs uses repeated excisions to

remove small pieces of cancer from the skin. Each piece is

evaluated under the microscope, and the procedure contin-

ues until there is no cancer. On average, two to three stages

(one stage involves removal of skin, preparation of slides

from that skin, and evaluation of the slides) are required to

obtained clear margins.

Mohs surgery is frequently used to remove skin cancer

from the face, ears, and neck. Basal cell and squamous cell

carcinoma are the two most frequent skin cancers removed

using Mohs surgery. Mohs is also used for skin cancer that

has recurred, skin cancer with aggressive pathology or skin

cancers that are bigger than 2 cm.

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MOHS SURGERY INVOLVES 5 STEPS

1. Numbing the skin with a local anesthetic

2. Surgical removal of a thin layer of skin containing the skin

cancer

3. Dividing the specimen into slices that are numbered,

mapped, color-coded, sectioned, and stained in the lab
(this is done in the laboratory while you wait).

4. Examination of the tissue by the Mohs Surgeon under

the microscope to determine if the entire tumor has
been removed

5. If the tumor is removed completely, the skin defect is

repaired. Steps 1 through 4 are repeated until the skin
is free of cancer

Mohs evaluates nearly 100 percent of the edge of a

cancer and this is responsible for the high cure rates.

However, the surgery is only as good as the physician

performing it, and the laboratory technician making the

slides. If either is not very skilled, there may be gaps in the

evaluation, which result in recurrences. Following surgery,

there are several options to repair the hole left in the skin.

In many cases, the dermatologic surgeon will repair the

defect using skin from nearby areas (fl aps) or skin from a

distant area (grafts). Some dermatologists only perform the

excision of the skin cancer and leave the repair work to a

plastic surgeon.

Finally, there are instances when no intervention provides

the best outcome, known as secondary intention healing. The

decision of who should repair the defect should be made by

you in concert with your Mohs surgeon. I tend to repair them

myself, unless the patient requests a plastic surgeon.

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“No matter how skilled the physician, a scar is inevitable.”

Each stage of Mohs requires between 30 to 50 minutes for

tissue preparation, which means that a Mohs procedure may

take the better part of a full day, depending on the extent

of the skin cancer. If you are scheduled for this procedure,

bring a sweater, some food, and a book.

In Summary

Better public education and early detection and treat-

ment have resulted in a mortality rate that has not risen as

rapidly as the occurrence rate. To protect yourself and your

family from skin cancer, use sunscreens appropriate for your

skin type and environment, and learn the signs of melanoma.

Non-surgical treatment of skin cancer is the focus of a great

deal of research. Vaccines and other experimental treatments

offered by the National Cancer Institute, Duke, Dana Farber,

Memorial Sloan Kettering and MD Anderson are beginning to

offer promise for treatment. In the near future, the treatment

of these common skin cancers will most likely involve apply-

ing a cream instead of surgery.

More information on clinical trials for melanoma and all

cancers may be found at www.cancer.gov.

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CHAPTER

What the Future
Holds in the
Quest for
Perfect Skin

“Our never ending quest for

perfect skin is only in its infancy.

The future looks bright.”

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Feeling good about your appearance radiates confi dence and

improves your chances for success. We are fortunate to have

so many choices available to achieve these goals, beginning

with topical skincare and continuing to dermal fi llers, botuli-

num toxins, resurfacing agents, and cosmetic surgery.

The proliferation of non-surgical and minimally invasive

procedures has revolutionized the fi eld of cosmetic derma-

tology. Growth is being driven by scientifi c advancements

and new technologies, as well as consumer demands for

less invasive procedures with shorter healing times. New

technologies developed over the next few years will enable

us to achieve these goals faster, safer, and more effectively.

Advances in laser technologies, fi ller materials, and cosme-

ceuticals are promising developments. Some of these treat-

ments will stimulate the skin’s own regenerative processes

to achieve a younger appearance without relying on invasive

surgery.

Our ongoing quest for perfect skin is fueling revolution-

ary treatments. Medicine in general treats all people as if

they need the same exact procedures and products. Over

the next few years, this will change as therapies for the skin

more accurately refl ect the requirements of your individual

skin type and condition. The trend toward customization and

combination therapies will produce perfect skin.

The goal of my practice, my skincare products, and my

publications is to provide scientifi cally sound information. I

do not embrace trends because they are fashionable; nor do

I advocate procedures or products where the risks outweigh

the benefi ts.

As a dermatologist, my most rewarding outcomes are

happy and satisfi ed patients. Dermatologic surgeons strive

to take our patients’ concerns very seriously. The simplest

procedure can take on great signifi cance to the person

undergoing it. I hope that my enthusiasm for my profession

is transmitted clearly to my staff as well as to my patients

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and colleagues. It is gratifying to me to help my patients look

their best and have healthy skin.

In an age of tremendous advancement in the knowledge

and tools available for treating aging skin, changes in basic

science, technology and products come at a rapid pace. The

Internet and telemedicine allow us to share experiences and

discoveries with colleagues all over the world in real time.

Growth within the fi eld of cosmetic dermatology over the

past decade has been dramatic and shows no sign of slowing

down. It is an evolving specialty limited only by the creativ-

ity and talent of those who practice within the specialty.

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Glossary

Ablation—Vaporization of the most superfi cial layers of skin

Acne—A chronic skin condition characterized by an infl am-

matory eruption of the skin that occurs when a hair follicle

gets plugged with sebum and dead cells. Rising hormone

levels stimulate oil glands, which cause clogged pores and

infl ammation

Actinic Keratosis—(Solar keratosis) A lesion that is dry,

scaly, rough, and tan or pink caused by sun exposure; consid-

ered precancerous

Alkaline—A non-acid substance with a pH greater than 7

Allantoin—A botanical extract said to heal and soothe. Used

in creams and topical preparations for the skin

Allergen—A substance that can cause allergic reaction

Allograft—A graft from the same species as the recipient; as

in human skin

Alopecia—A condition of hair loss

Alpha Hydroxy Acid—(AHA) A group of acids derived from

foods such as fruit and milk, which can improve the texture

of the skin by removing layers of dead cells and encourag-

ing cell regeneration. There are many AHAs but the most

common forms are Lactic Acid, Glycolic Acid, Pyruvic Acid,

Tartaric Acid, and Maleic Acid

Anemia—A pathological defi ciency in the oxygen-carrying

component of the blood; measured in unit volume concen-

trations of hemoglobin, red blood cell volume, or red blood

cell number

Antioxidant—A substance designed to prevent a chemical

reaction with oxygen, e.g. vitamins C, E, A, grape seed, and

green tea

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Arnica—A botanical derived from a mountain plant with

antiseptic, astringent, antimicrobial, and anti-infl ammatory

properties

Ascorbyl Palmitate—A synthetic form of vitamin C that

can reach tissue areas which ascorbic acid cannot

Autologous—Occurring naturally in a certain type of tissue

of the body

Basal Cell Carcinoma—Cancer of one of the innermost

cells of the deeper epidermis of the skin

Benzoyl Peroxide—An antibacterial ingredient commonly

used to treat acne

Beta Hydroxy Acid (Salicylic Acid)—A family of acids that

enhance cell renewal; found naturally in willow bark

Bioactive—Substances that achieve cosmetic results by

some degree of physiological action, e.g. fruit acids

Bleaching Agents—Substances which slow down or block

the production of melanin to lighten age spots and fade

areas of hyperpigmentation, i.e. Hydroquinone, Kojic Acid,

and Azelaic Acid

Botanical—Refers to products derived from plants

Botulinum Toxin—A naturally occurring toxin that is injected

into facial muscles to paralyze them temporarily and eliminate

expression lines of the face, around the eyes, and the neck

Buffer—An additive that adjusts the pH balance of a skin

preparation

Capillary—The smallest type of blood vessel in the body;

spider veins, for instance, are actually small capillaries com-

monly found on the face or legs

Carbon Dioxide—Laser technology that can be used to

resurface moderate to deep facial wrinkles, scars, and can

also be used as a cutting tool

Glossary

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Cauterize—To burn or sear abnormal tissue with a cautery

or caustic instrument such as a laser

Cellulite—Deposits of fat, toxins, and fl uids trapped in

pockets beneath the skin; more common in women

Chemical Peel—A procedure in which a solution of varying

strengths is applied to the entire face or to specifi c areas, such as

around the mouth, to peel away the skin’s top layers. Common

peeling agents include—Alpha Hydroxy Acid, Beta Hydroxy

Acid, Trichloroacetic Acid (TCA), Jessner’s Solution, and Phenol

Co Enzyme Q10—A renewal agent that stimulates natural

cell energy production and regenerates vitamin E

Collagen—A primary component of human skin that gives

it resiliency, suppleness and tone, and breaks down with age

due to muscle movement and environmental damage

Comedones—Open (blackheads) and closed (whiteheads)

formed when pores become clogged with oils and impurities

Commissure—The area where two anatomic parts meet,

as in the corner of the eye or the lips; typically referring to a

fold or crease

Corrugator—Muscle that is responsible for causing the

glabellar (vertical) lines that form between the eyebrows

Cosmeceutical—A substance that falls between the classifi -

cation of a drug and a cosmetic, i.e. non-prescription over-the-

counter formulations that provide pharmaceutical benefi ts

Crust—Surface layer formed by the drying of a bodily

secretion

Cryosurgery—Surgery in which diseased or abnormal

tissue (as a tumor or wart) is destroyed or removed by

freezing (as by the use of liquid nitrogen)

Cupid’s Bow—The double curve of the upper lip that

resembles a curved bow with reversed curve ends

Dermabrasion—Non-surgical resurfacing procedure in

which a hand-held rotary wheel is used to remove the top

layer of skin

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Dermal Fillers—A category of substances that are either

injected or implanted to shape and form overlying tissue

Dermatitis—An infl ammatory condition of the skin that is

characterized by itching and redness. Three categories of

dermatitis are: atopic, contact, and seborrheic

Dermatopathology—Pathology of the skin

Dermis—The layer of skin composed of collagen and

elastin, lying beneath the epidermis (outer layer) and above

the subcutaneous layers

Diode—Contact laser technology that cuts and coagulates

tissue

Ecchymosis—The passage of blood from ruptured blood

vessels into subcutaneous tissue, marked by a purple discol-

oration of the skin

Echinacea—A natural substance thought to boost the

immune system, and have anti-itching and soothing

properties

Eczema—A chronic skin condition characterized by super-

fi cial infl ation in areas of the skin and scalp

Edema—An excess accumulation of fl uid in the connective

tissue

Elastin—A protein that is similar to collagen and the chief

constituent of elastic fi bers; also used as a surface protective

agent in cosmetics to alleviate dry skin

Electrolysis—Use of electric current to permanently

destroy the hair’s root bulb

Electromyograph—An instrument used in the diagnosis of

neuromuscular disorders that produces an audio or visual

record of the electrical activity of a skeletal muscle by

means of an electrode inserted into the muscle or placed

on the skin

Electromyography—The diagnosis of neuromuscular

disorders with the use of an electromyograph

Epidermis—The outermost layer of the skin

Glossary

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Epinephrine—A white to brownish crystalline compound

isolated from the adrenal glands of certain mammals, or

synthesized and used in medicine as a heart stimulant,

vasoconstrictor, and bronchial relaxant

Epithelialization—Regeneration of the epithelium or super-

fi cial layer of the skin, as occurs after laser resurfacing

Erbium—YAG: A type of ablative laser that produces energy

in a wavelength that penetrates the skin, is readily absorbed

by water (a major component of tissue cells), and scatters

the heat effects of the laser light

Erythema—Redness of the skin, as in post laser or other

resurfacing

Exfoliant—A material that removes dead surface skin cells

Exfoliation—To remove a layer of skin in fl akes; peel

Extrusion—The erosion of skin that causes an implant

(chin, lip, breast, etc.) to become partially exposed

Fibroblast—A cell from which connective tissue develops

Filler—A category of substances that are either injected

or implanted to shape and form overlying tissue. Common

fi llers include—hyaluronic acid gel, bovine collagen, the

patient’s own fat or collagen from skin, and human donor

collagen.

Follicle—A sheath that surrounds the root of the hair

Forehead Lift—Also called a brow lift; pulls up droopy

brows and upper lids, and improves wrinkling and vertical

and horizontal frown lines. The open forehead lift is more

invasive than the endoscopic brow lift. An ‘open’ lift means

that you have an incision placed at or behind the ear through

which excess skin is removed and muscles are tightened.

An ‘endoscopic’ lift utilizes from three to fi ve tiny incisions

(1/2 to 1 inch) placed behind the hairline to remove muscles

that cause frowning and wrinkles and/or elevate your brows

Free Radicals—A destructive form of oxygen generated by

each cell in the body that destroys cellular membranes

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Frontalis—The muscle that enables the brows to move up

and down, and contributes to the formation of horizontal

wrinkles of the forehead

Glabella—The area between the eyebrows in the center

of the forehead where deep vertical lines and creases often

develop

Graft—A piece of tissue that is totally removed from one

part of the body and transferred to another area of the body,

e.g. fat, cartilage, bone, and skin

Glaucoma—Any of a group of eye diseases characterized

by abnormally high intraocular fl uid pressure, damaged

optic disk, hardening of the eyeball, and partial to complete

loss of vision

Glycerin—Used in moisturizers due to its water binding

capabilities

Glycolic acid—An organic substance found naturally in

unripe grapes and in the leaves of the wild grape, and pro-

duced artifi cially in many ways, as by the oxidation of glycol

Green Tea—An antioxidant rich in catechin polyphenols,

particularly epigallocatechin gallate (EGCG)

Hematoma—A localized accumulation of blood in the skin

caused by a blood vessel wall rupture; possible complication

of surgery that may have to be drained

Hirsuitism—Excessive growth of hair of normal or abnor-

mal distribution

Hyaluronic Acid—An acid found naturally in the body and

helps retain the skin’s natural moisture

Hydrocortisone—A glucocorticoid that is a derivative of

cortisone and is used in the treatment of rheumatoid arthritis

Hydroquinone—A bleaching agent that slows down or

blocks the production of melanin to lighten age spots and to

fade darkness and blotchiness

Glossary

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PALM BEACH PERFECT SKIN

Hyperpigmentation—Darkening of certain skin areas

through overproduction of melanin

Hypertrophic Scar—Thickened, raisedGlycolic acid— or

red scar tissue

Hypertrophy—Enlarged or thickened area

Hypoallergenic—A substance with a low chance of causing

allergy or skin irritation

Hypopigmentation—Reduction in the pigment cells in the

skin resulting in skin lightening

Hypoplasia—Incomplete or arrested development of an

organ or a part

Intense Pulsed Light—Very strong light without a light

beam that is one wavelength (color) or coherent. Different

wavelengths of light are sent into the skin to interact with

different targets in different tissues

Isolagen—Autologous fi ller fashioned from collagen from

your own skin that is grown in a laboratory, processed and

liquefi ed for later injection into wrinkles and folds

Jessner’s Solution—Pronounced ‘yes-nerz’; a pre-measured

solution formulated with Resorcinol, Salicylic AcidGlycolic

acid— and Lactic Acid with Ethanol; originally developed for

the treatment of acne

Keloid—Enlarged, permanentGlycolic acid— and thick-

ened scar formations that are more common in darker skin

types, and often run in families

Keratin—A surface protective agent with fi lm-forming and

moisturizing action

Kojic Acid—Natural skin-lightening agent derived from a

Japanese mushroom

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Lactic Acid—A component of the skin’s natural moistur-

izing factor

L-ascorbic Acid—The purest form of vitamin C; when

applied topically it is an antioxidant, anti-irritant and anti-

infl ammatory

Lentigo—Benign tan or brown colored lesion on the skin

from sun exposure

Lidocaine—A local anesthetic (trade name Xylocaine) used

topically on the skin and mucous membranes

Local Anesthesia—Medications (usually in the ‘caine’

family) that are injected into a surgical or treatment site to

cause temporary localized numbness

Lymphatic System—A network of structures, including

ducts and nodes that carry lymph fl uid from tissues to the

bloodstream

Malic Acid—A glycolic acid derived from apples

Marionette Lines—The vertical creases that form in the

corners of the mouth toward the jowls

Melanin—The pigment that gives skin its color

Melanocytes—An epidermal cell that produces melanin

Melanoma—The deadliest form of skin cancer character-

ized by a black or dark brown pigmented tumor

Melasma—A dark skin discoloration found on sun-exposed

areas of the face

Mentalis—A muscle that originates in the incisive fossa of

the mandible, inserts in the skin of the chin, raises the chin-

Glycolic acid— and pushes up the lower lip

Mexoryl

—Broad absorption UVA fi lter that protects

human skin from the effects of repeated suberythemal doses

of UVA

Micro-Dermabrasion—Also referred to as ‘derma-peeling’

or ‘micro-abrasion’; a mechanical blasting of the face with

Glossary

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174

PALM BEACH PERFECT SKIN

sterile microparticles that abrade or rub off the top skin

layer, then vacuum out the particles and the dead skin

Microabrasion—A tooth-whitening procedure using an

abrasive combined with hydrochloric acid

Milia—Tiny skin cysts that resemble whiteheads

Mohs Surgery—The destruction of malignant, infected or gan-

grenous tissue by the application of chemicals. The technique is

used successfully to remove superfi cial skin cancers using fi xa-

tion with a caustic or corrosive substance such as zinc chloride

Monitored Anesthesia Care—Also called ‘local with

intravenous sedation’ and ‘twilight’; medications are given

intravenously to induce a state of sleepiness and relieve pain,

supplemented with local anesthetic injections

Musculature—The system or arrangement of muscles in a

body or a body part

Nasion—The depression at the root of the nose that indi-

cates the junction where the forehead ends and the bridge

of the nose begins

Nasolabial Folds—The region of the face between the nose

and the corners of the lip; commonly referred to as ‘smile lines’

Necrosis—Dead skin cells

Non-Ablative Laser Resurfacing—A new class of lasers

that do not produce a deep burn and provide a much less

invasive treatment

Non-Comedogenic—Products that are formulated not to

clog the pores and cause pimples

Occlusive—Blocked

Orbicularis Oculi—The muscular body of the eyelid encir-

cling the eye and comprising the palpebral, orbital and lac-

rimal muscles. The palpebral muscle functions to close the

eyelid gently; the orbital muscle functions to close it more

energetically, as in winking

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Orbit—The cavity in the skull where the eyeballs, eye

muscles, nerves, and blood vessels rest.

Outpatient Surgery—Ambulatory surgery in which you are

discharged later the same day from the recovery room in a

hospital, offi ce surgical suite, or clinic

PABA—Para-aminobenzoic acid; found in the vitamin B com-

plex; used as an ingredient in some sunscreen products

Petrolatum—Used in creams, it softens and soothes skin,

and forms a fi lm to prevent moisture loss

Ph—The degree of acidity or alkalinity in the solution of

products

Phenol—Peeling formula applied to the skin to lighten pig-

ment, soften wrinkles, and improve scars; considered to be a

deep and more invasive peel

Phlebitis—Infl ammation of a vein

Photo Aging—Damage to the skin due to cumulative expo-

sure to the sun, i.e. wrinkles, age spots, and fi ne lines

Photosensitivity—Chemicals or topical ingredients that

cause the skin to be reactive when exposed to sunlight, such

as infl ammation, hyperpigmentation, and swelling

Platysma—A thin sheet of muscle located just beneath the

skin of the chin and neck

Platysmal Bands—Vertical strands of the muscle of the

neck that can become more prominent with age and are

often sutured or tightened during a face- or necklift

Polyphenol—A polyhydroxy phenol; especially an anti-

oxidant phytochemical (as chlorogenic acid) that tends to

prevent or neutralize the damaging effects of free radicals

Polysaccharide—Any of a class of carbohydrates, such as

starch and cellulose, consisting of a number of monosaccha-

rides joined by glycosidic bonds

Pore—Small opening of the sweat glands of the skin

Procerus—Muscle that works with the corrugator muscles and

contributes to the vertical frown lines between the eyebrows

Glossary

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176

PALM BEACH PERFECT SKIN

Porphyryl—A light activated photosynthesizer produced by

the drug ALA that reduces acne by disrupting activity in the

sebaceous glands

Psoriasis—A non-contagious infl ammatory skin disease

characterized by recurring reddish patches covered with

silvery scales

Ptosis—Pronounced (toe-sis); a term for drooping as in

eyelids, breasts, and brows

Resorcinol—In mild solutions, used as an antiseptic and as

a soothing preparation for itchy skin

Retin-A

(Tretinoin)—A topical medication derived from

vitamin A that is used to treat photoaging and acne

Retinol—A gentler non-prescription strength alternative to

Retinoic Acid. Retinol is a fast, active form of vitamin A that

works deep under the surface of the skin to visibly reduce

lines and wrinkles

Retinyl Palmitate—The reaction of Retinol and Palmitic

Acid, which normalizes skin by signifi cantly changing skin

composition to increase collagen, DNA, skin thickness, and

elasticity

Rhytidectomy (Facelift)—Surgical procedure which reju-

venates the face by tightening the underlying musculature,

removing excess fat deposits, and redraping sagging skin of

the lower face and neck. Incisions are placed in the hairline

and around the ears and/or under the chin

Rosacea—A common skin condition of the face, nose,

cheeks, and forehead that results in redness, pimples, dilated

blood vessels, and occasional pustules

Salicylic Acid—Used in many over-the-counter acne medi-

cations and to treat other skin disorders including dandruff,

psoriasis, calluses, corns, and warts

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Saline—Salt water commonly used as a fi ller for breast

implants and in the course of administering intravenous

fl uids

Schirmer’s Test—A test that assesses tear production in the

eyes and is helpful in treating dry eye syndrome

Sclerotherapy—The injection of one of several solutions

through a small needle directly into a vein to cause it to col-

lapse

Seborrheic Keratoses—A benign form of skin tumor that

commonly appears after age 40. The tumors are usually pain-

less and benign, but may become irritated and itch. They may

be cosmetically disfi guring and psychologically distressing as

a result

Septoplasty—An operation to unblock clogged sinuses in

order to improve breathing

Septum—The separating wall in the nose between the left

and right nasal passages

Silastic Sheeting—Patches or strips of silicone that may be

applied to the skin for extended time periods to soften and

reduce scarring

Silicone—A synthetic substance used in a gel-like form in

silicone breast implants, in a liquid injectable form for facial

areas and in other medical devices

SPF (Sun Protection Factor)—A scale used to rate the

level of protection sunscreens provide from UVB rays of the

sun

Spider Veins (Telangiectasias)—Dilated or broken blood

vessels near the surface of the skin

Squamous Cell Carcinoma—The second most common

skin cancer associated with chronic exposure to the sun. It

arises in the middle layers of the epidermis and occurs on

all areas of the body, including the lips and nails. Aggressive

subtypes can metastasize with fatal outcomes

Steroids—Any of a large number of hormonal substances

with similar basic chemical structure; produced mainly in

the adrenal cortex and gonads

Glossary

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PALM BEACH PERFECT SKIN

Stratum Corneum—Surface layer of epidermis

Striae—Commonly known as stretch marks; caused by thin-

ning of the underlying skin layer (dermis); appear fi rst as red,

raised lines, and then darken and fl atten gradually to form

shiny whitened streaks

Suction Assisted Lipectomy (Liposuction)—A proce-

dure in which localized collections of fat are removed from

the face and/or body by using a high vacuum device through

small incisions

Sun Block—A physical sunscreen or barrier against the

sun’s UV rays; available in creams or ointments

Tartaric Acid—A type of glycolic acid derived from apples

Tazarotene—A prescription topical retinoid (vitamin A

derivative) approved for treating mild to moderate plaque

psoriasis and photo aging

Tissue Engineering—The science of production of human

tissue ex vivo, (outside of the human body) as in growing

cartilage in tissue culture

Titanium Dioxide—A non-chemical, common agent used

in sunscreen products that works by physically blocking

the sun. It may be used alone or in combination with other

agents

Tocopherol—Chemical name for vitamin E; an antioxidant

Tretinoin—A derivative of vitamin A

Trichloroacetic Acid—A colorless, deliquescent, corrosive,

crystalline compound used topically as an astringent and

antiseptic

Tumescent—A method of anesthesia where large volumes

of local anesthetic and saline solution are injected to swell

the area to be operated on; commonly used in liposuction

and body contouring procedures

T-Zone—The area of the face that consists of the forehead,

nose, and the area around the mouth, including the chin

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Ultrasound—Application of a sound wave, a mechanical

vibration of more than 16,000 cycles per second

UVA—Long wavelengths emitted by the sun which take lon-

ger to produce a burn than UVB but penetrate deeper into

the skin to cause sun damage

UVB—Short wavelengths emitted by the sun which are

known to cause premature aging and skin cancer

Varicose Veins—Enlarged, swollen, and dilated veins just

below the surface of the skin, commonly found in the legs

and caused by the valves becoming fi lled with blood

Vermillion Border—The external pinkish-to-red area of the

upper and lower lips. It extends from the junction of the

lips with surrounding facial skin on the exterior to the labial

mucosa within the mouth

Wavelength—The distance between a given point on one

wave cycle and the corresponding point on the next succes-

sive wave cycle; the light of the wavelength produces a pure

color

Xanthoma—A fatty deposit in the skin that may appear on

the lower eyelids or elsewhere

YAG—Abbreviation for yttrium aluminum garnet; a crystal

used in some types of lasers

Zinc Oxide—Chemical ingredient that has soothing and

astringent qualities that can block the sun’s UV rays

Glossary

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PALM BEACH PERFECT SKIN

Resources

www.asds-net.org

www.aad.org

www.palmbeachcosmetic.com

www.weather.com

www.mohssurgery.org

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SKIN PATHOLOGY

Micrograph of Atrophic, Aged Skin

Here the epidermis has
become thinned while
the dermis has become
disorganized. This skin is
prone to bruising and will
appear old and thin.

Normal Skin Close Up Oil Gland

This is a photomicrograph
that demonstrates the
various layers of the skin.
At the top of the skin is
a basket weave layer of
dead skin cells known
as the stratum corneum.
Beneath this lies the viable
epidermal layer (purplish

in this photomicrograph). Deeper still is the thick organized
connective tissue composed of collagen and elastic ﬁbers that
support the outer epidermal layer. The vertically oriented white
structure is a sebaceous (oil) gland that is associated with a
hair follicle.

Micrograph of Actinic Keratosis

This photomicrograph
demonstrates disorganization
of the epidermal cells with
early signs of skin cancer.
The damage from the sun in
the dermis is evident in the
discoloration of the normally
pink staining collagen which
is blue here.

Lines, wrinkles
and folds graphically
illustrated

Courtesy of Medicis

RESTYLANE

Lip Augmentation

This woman had great
shape and contour of her
lips but wanted slightly
increased volume. I
accomplished this by
injecting Restylane.

Before

After

Before

Lip augmentation may also be performed for individuals
with small lips. In this woman, I injected two ml of
Hyaluronic acid to increase the size of her upper and
lower lips and give her the deﬁnition that she desired. This
improvement will last for between six and twelve months
in most individuals.

After

LIP AUGMENTATION

This is the same person
seen from the left side.
The deep wrinkles are
almost completely gone
in this view.

These are before and after
photographs of a 28 year
old woman treated with
Restylane. This treatment
signiﬁcantly reduced her
deep wrinkles and makes
her look and feel her age.

DEEP WRINKLES

Before

After

Before

After

BOTOX

Crows Feet

Botox used to treat the
crow’s feet. This woman
had overactive muscles
around her eyes causing
her wrinkles to worsen.
This made her appear
older and fatigued. By
using Botox to relax these
muscles a more youthful
and relaxed appearance is
obtained.

Wrinkles/Frown Lines

Botox used to treat the
crow’s feet. This woman
had overactive muscles
around her eyes causing
her wrinkles to worsen.
This made her appear
older and fatigued.

Before

After

Before

After

Sometimes Botox is not enough and a ﬁller is required
to smooth out wrinkles. This is the case in this instance
where years of frowning have etched in lines that need
to be ﬁlled. Fillers that can be used here include collagens,
Hyaluronic acids and Radiesse. In this instance, Restylane
was used in conjunction with Botox. (Studies show
that this combination results in increased duration of
correction for each.)

Before

After

BOTOX/COMBINATION THERAPIES

Liposuction is a safe and effective method of removing unwanted
fat. In this series of photographs, the signiﬁcant improvement
obtained in this woman’s neck and chin was accomplished in my
ofﬁce in about one hour.

Other areas that I treat with liposuction include the waist, hips,
thighs and arms. Men and women are treated although women
tend to be treated more frequently. These photographs show
results that I achieved in a middle aged woman that wanted to
lose some of the fat from her abdomen. She was not overweight
and needed to be sculpted—an ideal patient for liposuction.

LIPOSUCTION

Before

After

Before

After

SCLEROTHERAPY

Sclerotherapy is one of the most popular cosmetic dermatology
procedures performed in the United States. These photographs
show how injections of saline can safely and effectively eradicate
the tiny vessels that appear on the legs. This procedure was
performed about four times, spaced one month apart to obtain
this result.

Before

After

Accutane

, 7, 72-5

Acne, 7, 15, 17, 29, 30, 33, 53-4,

56-7, 64-5, 67, 71-8, 81, 83, 88,

90-2, 94, 114, 118, 139, 151,

166, 167, 172, 176, 188

cystic,

pustular,

Actinic keratoses, 11, 23, 32, 40,

90, 92, 149-51, 154, 181

Age spots, 24, 90, 167, 171, 175

Aging skin (See skin.)

Aldara, 151, 153, 155, 157-58

AlloDerm

, 9, 113-14

American Academy of

Dermatology, 29, 147, 184

Amevive, 86

Aminolevulinic acid, 77, 92, 151,

158

Anagen, 136

Antibiotics, 63, 73-4, 76, 80-2, 85,

93, 132, 137

Antioxidants, 6, 30, 47-49, 52,

54-5, 67-8, 82, 94, 185, 187

Artefi ll

, 117

Atopic dermatitis, 7, 84-5

Autologous fat, 28, 117

Avage

, 30, 32, 47, 60

Aveeno, 83

Basal cell carcinoma, 11, 14, 24,

149, 151-53, 158-59, 167

Benzoyl peroxides, 76

Blackheads, 72, 73, 78, 168

Botox

, 8, 28, 33, 62, 98-104,

Botulinum toxin, 8, 16-7, 28, 31,

33, 96-9, 101, 103, 164, 167, 181

Captique

, 9, 16-7, 25, 30, 61,

107-10, 112, 120, 181

Carbon dioxide (CO2) laser, 89

Carruthers, Alastair, 98

Carruthers, Jean, 98

Cetaphil, 68

Claritin, 85, 98

Collagen, 9, 15-7, 21, 22, 25-7,

33, 37, 49, 53-4, 56, 61, 89,

90, 93, 103, 107-110, 112-13,

115-17, 120, 143, 168-70, 172,

176, 187

Collagenase, 93

Comedones, 72, 168

Contour ThreadliftTM, 10, 122

Cosmeceuticals, 6, 13, 24, 31,

46-9, 54-5, 164, 168

Cosmetic Boot Camp, 14

CosmoDerm

, 9, 107, 109,

112-14, 120

CosmoPlast

, 9, 112-14, 120

Curettage, 12, 153, 159

Cymetra

, 9, 113-14

Dermasurgeon, 15, 122

Dermatopathology, 14-5, 20, 22,

136, 147, 159, 169, 184

Dermal fi llers, 10, 106-7, 120,

164, 169

Dermis, 23-5, 27, 33, 37, 47-8, 55,

113-14, 116, 118, 169, 178

Differin

, 76

Doxycycline, 73, 74, 80-1, 93

Eczema, 7, 17, 67, 69, 79, 83-5,

151, 169

Electrodessication, 12, 153, 159

Electrolysis, 138, 139, 169

Electro-optical synergy (ELOS),

8, 92

Enbrel, 86

Index

181

Index

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182

PALM BEACH PERFECT SKIN

Epidermis, 21-25, 27, 47, 55, 153,

155, 167, 169, 177-78

Erythromycin, 74, 76, 81

Eucerin, 46, 68

Fat, 15, 21, 25-8, 30, 33, 61, 96,

103, 106, 117, 126, 128-32,

154, 168, 170-71, 176-79

Fat transfer, 16-7, 33, 61, 96, 117,

132

Fitzpatrick Classifi cation, 36,

62-3, 65

Fraxel

, 8, 16, 25, 89, 94-5

Gentlewaves

, 93-4

Glycolic acid, 6, 18, 24, 33, 46-8,

51, 54, 64, 82-4, 143, 166, 171,

173, 178, 185, 190

Green tea, 30, 32-3, 46-7, 49-50,

52-4, 60, 66-8, 82, 93-4, 143,

166, 171, 185-191

Hair

growth, 33, 57, 136-39

reduction, 11, 135-36, 138,

140, 142-43

removal, 11, 26, 57, 136-42

Hormonal therapy, 7, 75

Hylaform

, 9, 16-7, 25, 30, 61,

107-10, 112, 120

Hylaform

Plus, 9, 16, 25, 61,

112, 120

Hyaluronic acid, 9, 15, 17, 27, 33,

52, 56, 103, 110-12, 120, 170-

71, 185-87

Hypopigmentation, 135, 172

Ideal Skin, 1, 6, 62, 65-6, 70

Intense pulsed light (IPL), 8, 28,

30, 50, 73, 77, 90-2, 94-6, 130,

134, 140, 142

Isolagen, 9, 16, 25, 66, 107,

112-13, 115, 170, 172

Juvederm

, 9, 16-7, 25, 28, 30,

61, 107-10, 112, 120

Levulan, 90, 93

Liposuction, 10, 15, 17, 30, 54,

124-31, 178, 185-86

Liquid silicones, 10, 119

Melanoma, 12, 14, 25, 37, 148-49,

153, 155-59, 162, 173, 184

Melasma, 173

Mexoryl, 40-1, 173

Microdermabrasion, 24, 30, 51,

67, 76, 93, 96, 143, 186, 190

Minocycline, 73, 80-1

Mohs surgery, 12, 152-53,

159-61, 174, 180, 184

Monheit, Gary, 106

Narins, Rhoda, 119

N-lite, 95

Non-ablative lasers, 89, 174

P. Acnes, 73

Palm Beach Peel®, 6, 18, 30, 33,

50-4, 64, 66-7, 82, 93, 185-91

Peels, 15, 17-8, 24, 27, 29-30,

33-4, 39, 48, 51, 55, 60-1, 67-8,

76, 93, 96

Perioral dermatitis, 82

Perlane

, 16, 25, 28, 30, 61,

107-9, 111, 120

Photothermolysis, 93, 140

Photodynamic therapy, 7, 8, 61,

77, 78, 81, 89, 92, 151, 155, 158

Pigment, 17, 20, 23-4, 31, 33, 36,

54-5, 62, 65, 88-9, 94-6, 134-35,

138-40, 142-43, 153, 155-56,

167, 172-73, 175, 186

Psoriasis, 7, 17, 54, 56, 79, 83,

85-6, 88, 176, 178

RadiesseTM, 10, 16-7, 25, 33,

103, 107-10, 117-18, 120

Radiofrequency, 8, 16, 27, 29, 33,

89, 91-2, 124, 133, 135

Raptiva, 86

Reloxin

, 8, 16, 28, 30, 33, 61,

96, 98-102

Remicade, 86, 153

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Restylane

, 9, 16-7, 25-6, 28, 30,

61-2, 74, 107-12, 120, 124

Restylane

Sub Q, 16, 107

Restylane

Touch, 107-09, 111

Retin-A

, 22, 30, 32, 47, 52, 60,

63-4, 76, 80, 85, 143, 176, 186

Retinoids, 47, 54, 76, 178

Rosacea, 7, 17, 33, 50, 56, 62, 65,

72, 79, 80-2, 90-1, 176, 189

Salicylic acid, 54, 63, 64, 67, 76-

8, 167, 172, 176

Sclerotherapy, 134-35, 177

Sculptra

, 9, 16-7, 25-8, 31, 33, 61,

74, 107-10, 115-16, 120, 124

Seasonal skincare, 6, 69

Sensitive skin (See skin.)

Shaving, 136-38

Singulair, 85

Skin cancer, 11, 12, 14-5, 17,

24-5, 39, 31, 37-40, 42-3, 50,

67, 69, 92, 145-49, 151, 153,

155, 157-62, 173-74, 177, 179

Skin layers, 25, 89, 178

Skin type, 6, 36, 43, 44, 62-5, 67,

76, 79-80, 82, 92, 107, 149,

162, 164, 172, 187

combination,

normal,

oily, 51, 63-5, 67, 78

sensitive, 7, 39, 62-3, 65, 76,

79, 82-4, 139, 189

Skincare, 6, 17-8, 23, 30, 32-4, 38,

46, 50, 52, 60, 65, 67, 69, 70,

72, 83

products, 17, 46, 65

SPF (See sun protection factor.)

Spider veins, 17, 167, 177

Squamous cell carcinoma, 12, 14,

38, 148-50, 153-55, 158-59, 177

Stretch marks, 11, 88, 133-35,

137, 139, 141, 143-44, 178

Striae, 143, 178

Subcutaneous tissue, 17, 23,

26-7, 110, 122, 169

Sulfa, 73-4, 76, 108, 189

Sun block, 37, 39, 42, 68, 93-4,

178

Sun damage, 5, 20-3, 27, 31-2, 38,

61, 63, 88, 92, 96, 149, 156, 179

Sun protection factor, 5, 36, 38-

44, 64, 177, 188, 189

Sunburn, 29, 37-9, 41, 50, 57, 74,

81, 91, 94, 148

Sunscreen, 35-7, 39-44, 64, 68,

162, 175, 177-78

chemical free, 188-89

Tazorac

, 76

Telangectasias, 80, 90, 92

Tetracycline, 73, 74, 80-1

Theraplex, 46, 68

Thermage

, 16, 25, 91

Threading, 10, 121-24

Tweezing, 137-38, 141

Vitamin C, 6, 30, 33, 46, 48-9,

54-5, 64, 67, 167, 173, 187

Weather Channel, 29, 42-3, 63,

180

Wrinkles, 5, 16, 17, 20-2, 25-31,

37-8, 40, 43, 47-8, 52, 54, 56,

61-3, 88, 92, 96, 98, 100, 106-7,

109-10, 112-13, 116-17, 119,

124, 167, 170-72, 175-76,

185-86, 190

creases, 20, 21-22, 26-8, 36,

91, 103, 107, 109, 111-12,

115-16, 118, 124, 128, 130,

171, 173

deep, 5, 20, 27, 107, 113

dynamic,

static,

28-9

Zantac, 85

Zyderm

, 9, 109, 112-14, 120

Zyplast

, 9, 112-14, 120

Zyrtec, 85

Index

183

Palm Beach Perfect FINAL 183

8/16/06 5:39:56 AM

184

PALM BEACH PERFECT SKIN

About
the Author

Dr. Kenneth R. Beer grew up in Woodmere, New York. He was

an A.B. Duke Scholar at Duke University, where he graduated

Phi Beta Kappa. Dr. Beer received his medical degree from

the University of Pennsylvania in 1989. After an internship

in internal medicine, he completed his dermatology resi-

dency and dermatopathology fellowship at the University

of Chicago. Dr. Beer is board certifi ed in dermatology by the

American Board of Dermatology and is also board certifi ed

in dermatopathology. At the present time, Dr. Beer is a clini-

cal instructor of dermatology at the University of Miami. He

has published numerous articles in medical journals, is a fre-

quent writer for popular magazines such as Elle and Allure,

and can be seen on television news programs. Dr. Beer is a

fellow of the American Academy of Dermatology (where he

serves on the Melanoma and Recredentialing Committees),

the American Society for Dermatopathology, the American

Society for Dermatologic Surgery, the American Society for

Mohs Surgery, and many other professional organizations.

Palm Beach Perfect FINAL 184

8/16/06 5:39:56 AM

Appendix

The Palm Beach Peel

System

Palm Beach Peel

Exfoliation Pads

(5%, 10% and 15%)

These convenient and easy to use exfoliation pads contain

glycolic acid. By using a gradually progressive three step sys-

tem, you can take control of your skincare regimen. To help

clear the outer layer of dead skins that can clog pores and

give the skin a dull appearance, the pads gently exfoliate and

remove oil from the surface of the skin. Witch hazel provides

astringent to the pads and this will help your skin look and

feel refreshed. Exfoliation pads are an integral part of any

anti-aging skincare program.

Directions for use: Remove a pad from the jar and wipe

the textured pad over the desired area to be cleansed, one

to two times daily.

Palm Beach Peel

Eye Rescue Formula

A nourishing serum formulated for the delicate skin under

the eye. There are few products that can effectively help

minimize the appearance of fi ne lines and wrinkles around

the eye. Eye Rescue Serum combines the hydrating benefi ts

of hyaluronic acids with antioxidants such as Green Tea

Extract, Coenzyme Q10, and liposomal vitamins A, C and E.

Directions for use: Apply Eye Rescue Serum at least twice

a day. If you are traveling, you should apply the Eye Rescue

Serum prior to fl ying and then at least once every three

hours.

Palm Beach Peel

Green Tea Antioxidant Cleanser

In order to avoid drying the skin and stripping vital oils

Appendix

185

Palm Beach Perfect FINAL 185

8/16/06 5:39:57 AM

186

PALM BEACH PERFECT SKIN

while cleansing, the Green Tea Antioxidant Cleanser is formu-

lated to gently cleanse and moisturize without leaving your

skin dry and irritated. I have combined liposomal vitamins A,

C and E as well as Green Tea and White Tea with Coenzyme

Q-10 in order to nourish the skin while cleansing it. This

cleanser should be part of any anti-aging skincare regimen.

Directions for use: Apply a tablespoon of cleanser to

moistened facial skin and gently massage for one to two

minutes. Rinse with lukewarm water and gently pat dry.

Cleanse twice a day.

Palm Beach Peel

Home Microdermabrasion Formula

We harnessed the power of bamboo to provide self-heating

crystals to enable our patients to obtain dermatology quality

microdermabrasion at home. The bamboo crystals deliver

a soothing wave of cleansing warmth as they remove dirt,

debris, oils, and other impurities that can clog the pores. As

with other types of microdermabrasion, the Home Micro-

dermabrasion system will help to minimize the appearance

of fi ne lines and pigment irregularities. It is the cornerstone

of any anti-aging skincare system.

Directions for use: Apply a pea size amount to face once

or twice a week. Gently massage into skin in a circular

motion, rinse with lukewarm water, and pat dry. Using

the Home Microdermabrasion Formula more than recom-

mended may result in skin irritation.

Palm Beach Peel

Retinol Recovery Serum

(.2%, .3% and .5%)

Retinol is the vitamin A derivative found in many prescrip-

tion and over-the-counter wrinkle treatments. It is the

precursor to Retin-A

. Retinol assists in minimizing the signs

of aging by reducing the appearance of fi ne lines, wrinkles,

and mottled pigmentation. Palm Beach Peel

Retinol Recov-

ery Serum also uses green tea hyaluronic acid (which will

increase moisture of the skin) to achieve smoother, fi rmer,

Palm Beach Perfect FINAL 186

8/16/06 5:39:57 AM

and more evenly toned skin. Increasing the concentration

of Retinol from .2% up to .5% will allow you to control the

Retinol Recovery for your skin (caution—higher concentra-

tion may cause irritation so proceed gradually). The Retinol

Recovery Serum is as close to a prescription strength anti-

aging cream as possible.

Directions for use: Apply to clean skin once every evening.

Palm Beach Peel

Antioxidant Rescue Serum

Rescue Serum is a lightweight, fast absorbing formula

combining hyaluronic acid with green tea and caffeine. The

green tea with caffeine maximizes the amount of antioxi-

dants delivered to the skin while the hyaluronic acid boosts

the hydration of the skin. Rescue Serum may help to reduce

skin redness and diminish pore size, while leaving the skin

smoother and more radiant. Palm Beach Peel

Rescue Serum

is recommended for all skin types.

Directions for use: Apply a pea size amount to skin after

cleansing in the morning and evening.

Palm Beach Peel

Growth Factor Serum

(10% & 15%)

Human growth factor TGF-beta-1 may help to stimulate col-

lagen synthesis and initiate skin repair mechanisms. I have

also included vitamin C (in either a 10% or 15% strength)

because this has also been shown to stimulate collagen

production. Growth Factor Serum may be slightly irritat-

ing when applied. It is intended to be used on skin that has

damage due to aging, sun, stress, smoking, or a combination

of these.

Directions for use: Apply a small amount to face, neck, and

chest after cleansing.

Palm Beach Peel

Moisturizing Formula

Moisturizing Formula is specifi cally designed to help add

moisture to dry skin. It is great for skin that is normally dry,

Appendix

187

Palm Beach Perfect FINAL 187

8/16/06 5:39:57 AM

188

PALM BEACH PERFECT SKIN

for when you are fl ying, or when you are in an area with low

humidity. I have included vitamins A, C, E, Green Tea Extract,

and Co-Q10 to help nourish your skin while moisturizing it.

Glycerin and Squalene, two natural humectants, are included

to draw moisture into the skin.

Directions for use: Apply any time your skin feels dry.

ANTI-AGING SKINCARE REGIME

Palm Beach Peel

Green Tea

Antioxidant Cleanser

Palm Beach Peel

Green Tea

Antioxidant Cleanser Palm

Beach Peel

Antioxidant Rescue

Serum

Palm Beach Peel

Exfoliation

Pads

Palm Beach Peel

Antioxidant

Moisturizing Formula

Palm Beach Peel

Growth Factor

Serum

Palm Beach Peel

Eye Rescue

Formula

Palm Beach Peel

Antioxidant

Moisturizing Formula

Chemical Free SPF 30

Palm Beach Peel

Eye Rescue

Formula

ACNE SKINCARE REGIME

Acne Cleanser

Acne Treatment Pads

Palm Beach Peel

Antioxidant

Moisturizing Formula

Palm Beach Peel

Antioxidant

Moisturizing Formula

Palm Beach Peel

Eye Rescue

Formula

Palm Beach Peel

Eye Rescue

Formula

Chemical Free SPF 30

Palm Beach Peel

Home

Dermabrasion Formula

Palm Beach Perfect FINAL 188

8/16/06 5:39:58 AM

SENSITIVE SKIN & ROSACEA CARE REGIME

Palm Beach Peel

Green Tea

Antioxidant Cleanser

Palm Beach Peel

Green Tea

Antioxidant Cleanser

Palm Beach Peel

Antioxidant

Rescue Serum

Palm Beach Peel

Retinol

Recovery Serum

Palm Beach Peel

Antioxidant

Moisturizing Formula

Palm Beach Peel® Antioxidant
Moisturizing Formula

Chemical Free SPF 30

Palm Beach Peel

Home

Dermabrasion Formula

Palm Beach Peel

Crystal

INGREDIENTS: Butylene Glycol, Sodium Silicoaluminate,

Bambusa arundinacia (Bamboo) Stem Extract, PEG-8,

Camellia sinensis (Green Tea), White Tea, Ascorbyl Palmi-

tate, Retinyl Palmitate, Tocopheryl Acetate, Dimethicone,

Methyl Gluceth-20, Hydroxyproplcellulose, Hydroxypropyl-

methylcellulose, Petrolatum, Titanium Dioxide.

Palm Beach Peel

Antioxidant Cleanser

INGREDIENTS: Purifi ed Water, Sorbitol, Cetyl Alcohol, Stea-

ryl Alcohol, Ammonium Lauryl Sulfate, Camellia sinensis

(Green Tea) Leaf Extract, White Tea, Camellia Sinensis

(Green Tea) Polyphenols, Soy Phospholipids, Citrus auran-

tium dulcis (Orange) Fruit Extract, Retinyl Palmitate,

Ascorbyl Palmitate, Tocophenyl Acetate, Coenzyme Q10,

Superoxide Dismutase, Ascorbyl Glucosamine, Disodium

EDTA, Bisabolol, Methylparaben, Propylparaben, Imidaz-

olidinyl Urea.

Appendix

189

Palm Beach Perfect FINAL 189

8/16/06 5:39:58 AM

Order Form

THE PALM BEACH PEEL SYSTEM ORDER FORM

Product Name

Price

Quantity

Palm Beach Peel

Exfoliation Pads 10%

Convenient easy-to-use pads contain 10%
glycolic acid.

$40.00

___________

Palm Beach Peel

Exfoliation Pads 15%

Convenient easy to use pads contain 15%
glycolic acid.

$40.00

___________

Palm Beach Peel

Exfoliation Pads 20%

Convenient easy to use pads contain 20%
glycolic acid.

$40.00

___________

Palm Beach Peel

Retinol Recovery Serum 2x

Retinol assists in minimizing signs of aging.

$80.00

___________

Palm Beach Peel

Retinol Recovery Serum 3x

Retinol assists in minimizing signs of aging.

$90.00

___________

Palm Beach Peel

Retinol Recovery Serum 5x

Retinol assists in minimizing signs of aging.

$100.00 ___________

Palm Beach Peel

Eye Rescue Formula

Nourishing serum effectively minimizes the
appearance of fi ne lines and wrinkles around
the eye.

$45.00

___________

Palm Beach Peel

Green Tea Antioxidant Cleanser

Gentle cleanser moisturizes without drying the
skin and stripping vital oils.

$45.00

___________

Palm Beach Peel

Home Dermabrasion Formula

Microdermabrasion at home. A soothing
wave of cleansing warmth.

$65.00

___________

Palm Beach Peel

Antioxidant Moisturizing Formula

Specially designed to help add moisture to dry skin.
Contains vitamins A, C, E Green Tea Extract
and Co-Q10.

$40.00

__________

Palm Beach Peel

10% Growth Factor Serum

Antioxidant serum delivers skin enhancing
benefi ts.

$120.00

__________

Palm Beach Peel

15% Growth Factor Serum

Antioxidant serum delivers skin enhancing
benefi ts.

$135.00

__________

Palm Beach Peel

Green Tea Rescue Serum

Serum has a high concentration of antioxidants
which may help reverse aging.

$135.00

__________

Palm Beach Perfect FINAL 190

8/16/06 5:39:58 AM

Product Name

Price

Quantity

Palm Beach Peel

Green Tea Collection

Collection includes Green Tea Cleanser, Home
Dermabrasion Formula, Green Tea Serum and
Palm Beach Peel

Antioxidant Moisturizing

Formula

$160.00

__________

Palm Beach Peel

Skin Resuscitation Collection

Collection includes Palm Beach Peel

Home

Dermabrasion, Eye Rescue Formula, Retinol
Recovery Serum 5x Green Tea Cleanser

$195.00 __________

Palm Beach Peel

Ultimate Collection

Collection includes Green Tea Antioxidant
Cleanser, Growth Factor 10% Palm Beach
Peel

Home Dermabrasion, Eye Rescue

Formula, Palm

Beach Peel

Antioxidant

Moisturizing Formula

$245.00

__________

Order Total

_______________________________

Florida Sales Tax (6%)

_______________________________

Total Amount Enclosed

_______________________________

Billing Address:

Full Name

__________________________________________________________

Address

__________________________________________________________

Address Line 2 _____________________________________________________

City ____________ State/Province _______ ZIP or Postal Code _________

Country

__________________________________________________________

Daytime Telephone ______________ Daytime Telephone ______________

E-mail Address ____________________________________________________

Shipping Address (if different from above):

Full Name

__________________________________________________________

Address

__________________________________________________________

Address Line 2 _____________________________________________________

City ____________ State/Province _______ ZIP or Postal Code _________

Country

__________________________________________________________

Credit Card Information

____________________________________

Name on Credit Card

____________________________________

Type

____________________________________

Number

____________________________________

Expiration Date

____________________________________

MAIL, FAX, EMAIL or CALL IN YOUR ORDER TO:

Kenneth R. Beer, MD

Palm Beach Esthetic Center • 1500 North Dixie Highway, Suite 305

West Palm Beach, FL 33401-2717

Phone 561-655-9055 • Fax 561-655-9233

contactus@idealskin.com

Monthly shipments available. If you elect to do this check here

and your credit card will be charged monthly for each shipment.

Palm Beach Perfect FINAL 191

8/16/06 5:39:59 AM

Notes

Palm Beach Perfect FINAL 192

8/16/06 5:39:59 AM

Document Outline

Title
Acknowledgements
Contents
1 The Structure of the Skin & How This Changes with Aging
2 The Sun & Your Skin
3 Skin Maintenance & Improvement
4 A Lifetime of Perfect Skin
5 Maintaining Clear Skin When You Have Acne
6 Common Conditions That Interfere with the Perfect Skin Plan: Rosacea, Sensitive Skin, Eczema, Psoriasis
7 Lasers & Light Sources
8 All About Botulinum Toxin
9 Fillers for Facial Rejuvenation
10 Holding on by a Thread
11 Tumescent Liposuction
12 Eradicating Veins, Unwanted Hair, & Stretch Marks
13 Advances in the Diagnosis & Treatment of Skin Cancers
14 What the Future Holds in the Quest for Perfect Skin
Glossary
Resources
Images
Index
About the Author
Appendix
Order Form

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