Pinning the Skin and Anti-Aging - by Dr. Tomasello

You have very thin skin. No, that is not an insult, it’s a fact.

Skin covering your body has many variations of thickness. The upper layer of skin is the epidermis, whose depth on the face (and the rest of the body) is fairly uniform. The differences in skin thickness have much more to do with the depth of the underlying dermis. The thinnest skin on your body is behind your ears and on your eyelids. These areas have an average thickness of 500 microns (or 0.5 mm). The skin on the face is about the thickness of a dime (1.3 mm). Take a dime out of your pocket or purse and take a look at it. All of the products, procedures and treatments you see advertised are aimed at making your dime-thickness skin more beautiful, youthful, clear and vibrant. That’s what it is all about. One thin dime.

Without the paper-thin upper layer of the epidermis known as the stratum corneum, we would be toast.  We would be dehydrated and succumb to a myriad of bacteria and viruses.  So the skin is pretty awesome indeed. You may think that attaining youthful and beautiful skin is a very complicated endeavor requiring expensive creams and serums and procedures costing an arm and a leg.

Guess what? It’s not that complicated at all.

Before publishing my book I spoke to hundreds of people with a strong desire to have a more youthful and beautiful appearance.  Two common themes resonated.  “It is too complicated” and “I have no idea where to start.” Many just throw their hands up in disgust and head to the dermatologist or medical spa and say “fix me.”  These specialists can surely help you. The fact is that you have WAY more power in becoming beautiful than you realize. I am certain of this.

Pinning the Skin

In my recent interview with skin care expert Lillian Martini, I discussed a concept which needs elaboration. What ‘Pinning the Skin’ means is treating the skin from the outside-in and the inside-out.  It means literally ‘squeezing’ the skin between powerful anti-aging factors and treatments. Blood flow only comes to ONE layer of the skin; the dermis. That means that the epidermis, that layer of skin you see when you look anywhere on your body has NO DIRECT BLOOD FLOW. What does this mean in terms of anti-aging? For one thing, it means your epidermis needs a lot of help, from you…and blood flow from the dermis.

Hit the Outside

Skin Ingredients:  Making your skin look younger and beautiful begins with hydration and SPF protection. After this, it is about the right ingredients to clear away unwanted pigment, reduce redness (including acne and rosacea) and improve collagen and elastin to remove fine lines and wrinkles. Using the RIGHT ingredients is FAR more important than using A LOT of ingredients. Face it, if you had fewer red or brown discolorations and a disappearance of fine lines and wrinkles … you would certainly be smiling, would you not?

Treatments and Procedures: Botox, dermal fillers, cosmetic laser treatments, microneedling, microdermabrasion, chemical peels and many others help improve the appearance of your skin. These are all hitting your skin from the outside-in as well. I talk about these all in detail in my book and website in regard to what each exactly each does to help your skin appear more supple, young, clear and vibrant.  They all work very well indeed and can help to treat a myriad of skin conditions and aging concerns.

Now Hit the Inside

Powerhouse anti-oxidants and nutrients: When you eat some really high power anti-oxidant like spinach or kale, those nutrients and antioxidants are absorbed through the intestinal tract, enter the blood stream and end up in the capillaries of the DERMIS.  Now you have antioxidants in the dermis and these dermal capillaries also supply the epidermis. If you are using an antioxidant Vitamin A serum and eating powerhouse antioxidants, you have literally pinned the skin between two powerful antioxidant sources: external and internal. How is it possible for the skin NOT to improve when you are attacking it like this? From an anatomical and physiologic standpoint, the skin has literally no option but to improve.

Now let’s take a scenario where we could hurt the skin from the outside and inside. No SPF protection. Here come free radicals from UVA rays which increase collagenase; an enzyme which literally destroys collagen. Combine this with some fried food in your diet.  Plant oils oxidize in the high temperatures used in frying which causes increased free radicals. In the scenario above we ‘pinned the skin’ with antioxidants. In this example we are ‘pinning the skin’ with free radicals.

In Summary:

SPF, one cream and one dietary change gives guaranteed anti-aging results.

No SPF and fried food pinned our skin with free radicals which assured our skin would age more quickly.

Helping your skin look more youthful and beautiful is possible for anyone provided there are simple, consistent measures taken. I am not saying that eating spinach and using vitamin A is going to improve your skin overnight. However, if done consistently, it HAS to bring anti-aging results.

This is a dime-thickness skin layer. Not rocket-science. You can do it. For decades my goal has remained to try to break anti-aging, skin care and medical aesthetics down into terms that are understandable to all with an approach that is not scary or daunting. Knowledge will always be powerful.

Be well and be good to your skin

Dean M. Tomasello, MD

Keeping Anti-Aging Simple- by Dr. Tomasello

When it comes to anti-aging, it is best to think of the skin simply and layer by layer. Most every skin care, anti-aging or aesthetic procedure is aimed at helping one or more specific skin factors. I put these into three basic categories. The first step in anti-aging is to understand what each layer is composed of and what we need to do to help that area ‘act’ younger.

Anti-Aging Skin Category 1– The Epidermis

The epidermis is the outermost skin layer composed of five distinct areas. New cells come from the bottom (stratum basale) and move upward until they reach the top (stratum corneum) layer. This top layer is composed of dead cells that serve many protective and moisture-retaining functions.  In regard to the epidermis, anti-aging products and treatments should:

1. Clear excess dead skin cells from the skin surface (stratum corneum).
2. Stimulate new cell growth from the stratum basale.
3. Neutralize free radicals.

Anti-Agin Skin Category 2 – The Dermis

The dermis is below the epidermis. Here collagen and elastin are of utmost importance. In this layer, cells calledfibroblasts make collagen and elastin. 70% of the dermis is made up of collagen. Think of collagen and elastin as ‘architecture’ supporting the epidermis. In order to have beautiful and youthful skin you need a soft and smooth epidermis supported well by a healthy dermis. Collagen and elastin in the dermis keep the skin tight, elastic and firm. Effective products and treatments that help the dermis will:

1. Stimulate fibroblasts to make more collagen and elastin.
2. Clear free radicals that can break down collagen and elastin.
3. Improve the function or prevent breakdown of collagen and elastin through the use of neurotoxins and dermal fillers. More collagen and elastin equates to tighter and firmer skin.
4. Improve blood flow to the dermis. The blood flow in the dermis supplies oxygen and nutrients to both the dermis and epidermis. A diet filled with powerhouse anti-oxidants means these crucial anti-aging dietary factors are hitting these skin layers from the inside-out.

Anti-Aging Skin Category 3 – Moisture and UV Protection

This is an important maintenance category. The skin needs to be nurtured and protected. Hydrated skin is youthful and happy skin. Avoid stripping protective oils and keep the skin well hydrated. Block UV rays from your skin as much as possible. These rays cause the formation of hefty amounts free radicals in both the epidermis and dermis resulting in premature skin aging.

How Neurotoxins (like Botox) and Dermal Fillers Fit into Category 2

Neurotoxins (i.e. Botox, Dysport and Xeomin) inhibit facial muscle movement. Every time you yawn, smile, laugh, squint or frown, the small muscles around the eyes, brow and forehead repeatedly contract and squeeze the skin (and collagen) between them. With continued movement, fine lines and wrinkles form and deepen.  This is most noticeable around the eyes (crow’s feet), brow (between the eyebrows) and the forehead. The anti-aging effects of neurotoxins occur due to a temporary block of these facial muscles.

Botox does more than just stop muscle movement though; it goes a step further. A study in the JAMA Facial Plastic Surgery (May 2015) showed that Botox increased the stretch and elastic recoil in the skin of women studied.  This mimicked younger skin. Therefore, by relaxing the muscles, you now literally have less wear and tear on the collagen and elastin. Yes, Botox relaxes facial muscles, however it also gives collagen and elastin a chance to stretch out and strengthen. Through this, we are improving the strength and elasticity of the dermis. Our supporting architecture is improved. Therefore, Botox (and other neurotoxins) brings powerful anti-aging power beyond what was originally thought.

Dermal Fillers (i.e. Restylane, Juvederm, and Radiesse) do more than just ‘fill in’ wrinkles. If the injector is skilled, the dermal filler will both fill in the area of deficit as well as stimulate the growth of collagen and elastin. A large ‘bolus’ injection of a filler into a wrinkle is not optimal. Spreading the filler out during the injection (commonly referred to as ‘fanning’) is best.

1. Spreading the filler out presents the dermis with a larger product ‘surface area.’ For hyaluronic acid fillers like Restylane, this means a greater moisture-retaining potential. For a product like Radiesse, it means a larger collagen stimulating area.
2. The process of spreading the filler out also serves to cause a greater stimulation of collagen-producing fibroblasts in the dermis. It is true that the injection itself can elicit anti-aging effects.

There are countless products and treatments which can help your skin look younger. It is important to remember to keep it simple. With each product used or procedure performed, be aware of which category is going to benefit most. Having this awareness will be of great benefit to you in accomplishing your anti-aging goals

In “Winning Skin” I discuss how each skin care ingredient, aesthetic treatment, cosmetic procedure and dietary factor helps one or more of these important three categories.

Be good to yourself and your skin!

Dean M. Tomasello, MD

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Botox vs. Xeomin -by Dr. Tomasello

Xeomin (Zee-Oh-Min) from Merz Aesthetics has been used in Europe since 2008. It received FDA approval in November of 2011 and is the newest Neurotoxin on the US market. However, Xeomin (inco-botulinumtoxinA) did not come out of the gate smoothly. It was pulled in March of 2012 following a federal court ruling that Merz collected consumer lists and sales figures from Allergan (the maker of Botox). The confidential information was obtained through Allergan sales representatives. So after a rocky start, it was re-launched in early 2013.

Botox and Xeomin are very similar. Xeomin is sometimes described as “The Naked Botox” due to its absence of the carrier proteins present with Botox. In theory this absence of protein carriers results in fewer allergic reactions or resistance to the neurotoxin. Xeomin, due to its lack of these additives, does not need to be refrigerated. It is the only one of the three neurotoxins that has this feature.

Lets discuss these ‘advantages’

1. In theory, less people will develop resistance via antibody formation. If you have a cold, the body makes antibodies to fight off that virus. When that virus comes around again, the antibodies quickly neutralize it. Hence, the body is resistant. The human body doesn’t commonly makeantibodies to Botox In the small percentage that do, the effect and duration of action of Botox are markedly reduced. In the very few patients I have seen with this resistance, I switch to Dysport.
2. In theory, fewer allergic reactions. Merz aesthetics attributes this to the absence of carrier proteins as well. After injecting Botox for over 10 years I can honestly say I have never experienced a patient allergy to Botox. James Bonaparte, MD, Cosmetic Surgeon and researcher would seem to agree as he notes, “After reviewing 20,000 patients and a number of randomized studies, there are no reports of allergies with Botox.”
3. No refrigeration needed. Botox and Dysport are shipped in dry ice. Hence, Xeomin is cheaper to ship and adds a measure of convenience here.

Quicker onset or Longer lasting? No.

Botox and Xeomin are essentially identical in terms of the active neurotoxin ingredient. One unit of Botox = One unit of Xeomin.  (One unit of Botox = 2.5 Units of Dysport). Thus the conversion is simple. If you had a good result on your brow with 20 units of Botox, you should get the same result with 20 units of Xeomin (or 50 units of Dysport).

Dysport clearly has a faster onset of action than Botox. (1-3 days vs. 3-5 days on average). Xeomin’s 3-5 day onset of action mirrors Botox.  There are case reports claiming Xeomin works faster, however I have been unable to locate literature supporting this. Certainly if such a study existed, Merz Aesthetics would have let us know. Equally common are reports of Xeomin being cheaper because it ‘doesn’t last as long.’ There is no study supporting this either.

Xeomin and Botox both last 3-6 months. Results vary person to person and are affected by factors such as activity level, amount injected and area injected.

Cost

Xeomin may cost the doctor less than Botox depending on how much they are buying (up to 15% less). Whether or not they pass the savings along to you depends on each individual practice.  Many offices, to simplify matters,  charge the same per unit price for Botox and Xeomin. Based on the practices I reviewed, the average for Botox is $12-$14/unit and Xeomin $9-12/unit. Overall the average savings is $1-2 less per unit of Xeomin (vs Botox). Merz Aesthetics has offered different promotions in the past, such as a $50 gift card when 30 units or more of Xeomin were purchased.

Having three products instead of one is good for consumers as each company is vying for your business and your loyalty. Through rebates, gift cards and award programs, many discounts are available as each company wants you using their product and are willing to reward you for doing so.

Tried and True Factor

Products like Coca-Cola, Heinz, Kleenex, Viagra, and Botox  have had great success along with names that bring forth a clear image to consumers. They are known and trusted brands. There are other colas, catsups, tissues, erectile dysfunction medications and neurotoxins, but if someone says “Botox”, the vast majority of the population knows what you are talking about. It’s the gold standard; the tried and true neurotoxin used a long time while giving predictable results. Dysport was called “The new Botox” and Xeomin has been called “The naked Botox.” Even competitors of Botox are described in ‘Botox’ terms. Botox is a strong, enduring and trusted brand.

The Xeomin Verdict

The most tangible benefits to recommend Xeomin are firstly, its slightly lower cost (in some offices), and secondly, the fact that it does not need to be refrigerated. The theories that it will cause less resistance or allergies are not likely to make one shred of difference in the success or failure of Xeomin.

As it stands in 2015, Botox is to medical aesthetics as CocaCola is to soft drinks. Time will tell how Xeomin will fit in as a player in the neurotoxin market. The fact that it really does NOT have a glaring downside is important. I certainly feel it is an effective and worthy neurotoxin to use as an alternative to Botox or Dysport. There are plenty of positives with Xeomin.  Similarly, there was much to recommend the soft drink ‘Slice’ …until Sierra Mist came along.

Be Well,

Dean M. Tomasello, MD

Dermal Fillers by Dr. Tomasello

I recently received a message from a LinkedIn connection who happily shared, “As you can see from my picture, I have been very fortunate to have perfect skin and no wrinkles.” Some people just hit the genetics lottery. The vast majority of us need a little help. Dermal fillers come to the rescue in a big way. And there is little doubt in this doctor’s mind that dermal fillers are here to stay. It has now been over a decade since Restylane was FDA approved (March, 2005) and another (Ellanse) will be the next dermal filler to hit the US. Dermal fillers are VERY popular. The reason is simple. They offer a safe and effective way to bring youthful results without expensive cosmetic surgery. Most patients who have had dermal fillers are happy and come back for more.

However, with the arrival of new dermal fillers and different formulations it can be difficult to determine which filler works best for each ‘wrinkle.’ Dermal fillers are approved by the FDA for treatment of specific areas of the face. Radiesse was approved by the FDA for treatment of naso-labial folds back in 2006. Last month it was approved for “improvement of volume loss on the dorsum (back) of the hands.” Dermal fillers are FDA approved for certain areas of the face, with other uses designated as ‘off label’ uses.

Here are the areas of the face that most people look to correct.

Juvederm Ultra

In 2010 Juvederm Ultra was FDA approved to last ‘up to a year.’ I heard a case report of  a woman who had Juvederm in her lips for a year and a half and wanted it removed because it just wouldn’t go away. That is rare. Juvederm Ultra is a sterile gel made up of crossed linked hyaluronic acid. I have been a fan of Juvederm but my experience is that it lasts 4-6 months, occasionally longer. It really depends on the area injected. Also, some people just break down the product faster than others. Areas like the mouth that have more movement tend to have a shorter life-span for dermal fillers. The naso-labial folds last longer. Juvederm has a very smooth consistency and is quite popular due to its multitude of effective uses.

Use Juvederm Ultra for naso-labial folds, lips, marionette lines & peri-oral lines

Restylane

Like Juvederm, Restylane is a sterile gel made up of crossed-linked hyaluronic acid. Restylane and Juvederm are popular because they work well and have strong safety profiles. Restylane’s cross-linked hyaluronic acid is smaller in size. This allows for better use in more delicate areas such as around the eyes, tear troughs, around the lips and “frown lines” between the eyebrows. Many times when trying to determine which filler is best it comes down to patient experience. If a patient had Juvederm Ultra in her lips or naso-labial folds and it lasted nearly a year, your best bet is to try it again. Restylane, like Juvederm Ultra last for 4-6 months and typically cost $400-$600 per syringe.

Use Restylane for tear troughs, lips, naso-labial folds, marionette lines, crow’s feet, peri-oral lines & brow lines.

Perlane and Juvederm Ultra Plus

Perlane is made by the same company (Medicis) that makes Restylane. Perlane’s cross-linked hyaluronic acid molecules are much larger; this makes it denser and thicker with a higher molecular weight. Perlane, therefore, works best for areas that need more volume such as deep naso-labial folds or to increase volume to the cheeks. Juvederm Ultra Plus works very similar to Perlane in this regard. These two products typically last longer (6-9 months) and do cost a bit more ($500-$750 per syringe).

Use Perlane and Juvederm Ultra Plus for cheek augmentation, naso-labial folds & marionette lines.

Prevelle and Prevelle Silk

Prevelle was FDA approved in 2008 and has been used worldwide. Prevelle Silk is just Prevelle plus lidocaine. It clearly is not as common as Restylane or Juvederm but there is indeed a place for it. Prevelle is at the opposite end of the spectrum than Perlane with a low molecular weight and is the smallest molecule in this class. Prevelle’s best use may be as an entry level filler; for those who may be new to dermal fillers or hesitant to make big changes. It tends to cause less swelling and is best used for fine lines and wrinkles as well as for lip augmentation. The downside with Prevelle is that it just doesn’t seem to last very long; typically 3-4 months. However, it is less expensive and if someone is hesitant and/or looking for subtle changes in the naso-labial folds, fine lines around the mouth or eyes or a mild lip augmentation, Prevelle may be a good option. It is typically around $400 per syringe. Those I have injected with Prevelle tended to not want dramatic changes and were pleased with the lower cost.

Use Prevelle for lips, naso-labial folds, peri-oral lines, tear troughs, marionette lines & brow lines.

Radiesse – Calcium Hydroxylapatite

Radiesse is a constituent of bone and cartilage. Unlike hyaluronic acid fillers that appear clear in the syringe, Radiesse has a milky-white consistency. Being thicker allows Radiesse to do a few things perhaps better than the hyaluronic acid fillers. I like Radiesse for cheek augmentation. It is a very robust filler and when injected into the cheeks tends to ‘hold’ the cheek up, almost giving it a subtle face-lift quality (also known as a ‘lifting’ effect). In addition, Radiesse stimulates new collagen. Radiesse can also be used to for naso-labial folds or marionette lines. It is a bit more expensive ($700-900 per syringe) however comes as a 1.5 ml syringe (vs. 1.0 with Restylane). Radiesse lasts longer too, typically about a year in most patients.

Use Radiesse for cheek augmentation, naso-labial folds & marionette lines. (Never in lips)

Juvederm Voluma (A hyaluronic acid and competitor of Radiesse)

The maker of Juvederm Voluma (Allergan) stated this product lasts for up to two years. Most experts will agree that Juvederm Voluma will last much longer than Juvederm Ultra, Restylane, Perlane or Prevelle, but not two years. In Allergan’s study 6-8 ml’s of Voluma was injected into subject’s cheeks. Now this is a large volume of Voluma. I suspect these people left looking like they had golf balls in their mouths. After two years they asked the people to grade if there was still Voluma present. A ‘yes’ meant they answered 1 or above on a scale of 1-6. Point to remember here is that Voluma does last longer than Juvederm Ultra but the reality is that it lasts a year (vs. 4-6 months). Voluma aims to do what Radiesse does, namely filling and lifting the cheeks. My opinion is that while Voluma does last as long as Radiesse and does a fantastic job filling naso-labial folds and marionette lines, I prefer Radiesse for the cheeks.

Use Juvederm Volema for cheek augmentation, naso-labial folds & marionette lines.

Scluptra – Poly-L-Lactic Acid

Sculptra is a collagen stimulator and is really in its own class and is not technically a dermal filler. Sculptra is injectedthroughout the face. Its goal is to bring volume to the entire face in areas such as the cheeks, naso-labial folds, marionette lines and chin. It is completed in a series of sessions 6 weeks apart. It works very slowly taking up to six months to see the full effect. Done correctly the results are very natural and subtle. I have left the use of Sculptra to the plastic surgeons or other experts. Sculptra has been used to correct the facial tissue loss seen with HIV patients, or hollowing of the face that is genetic in certain families. Also when plastic surgery is riskier in an older patient, Sculptra has been used as a strong alternative to surgery.

Belotero Balance 

Belotero is an excellent product. It really does well with treatment of naso-labial folds, marionette lines, lips, lip lines, tear troughs and other fine facial lines. There is less chance for a blue discoloration (Tyndall effect) after superficial injections and the cost is quite similar to comparable products currently on the market. Read more about Belotero Balance .

Making it comfortable

I have used many approaches to ensure patient comfort while performing dermal filler injections. For a period of time I used dental blocks, similar to what you may have at the dentist office. This seemed to be overkill as patients remained numb for hours after leaving the office. I next used Lidocaine Gel with Epinephrine. This is what I have found works the best. It is applied directly onto the skin for about 20-30 minutes before the procedure. It does an excellent job of numbing the area plus the Epinephrine constricts small arteries resulting in less bleeding and/or bruising. However, if you really want to feel ‘nothing’, the dental block is the way to go.

Also, most hyaluronic fillers come with a standard preparation and one ‘with lidocaine’. This helps a little bit at best, not so much during the injection but afterward when the injector smoothens the area injected to assure that there are no bumps. (A good injector should always do this by the way). Restylane, for instance has a preparation that comes with lidocaine which is called Restylane-L.

Guide to Dermal Fillers  (My preference)

Safely getting a great result 

Dermal fillers should not be used in pregnant or nursing patients, those taking aspirin or blood thinners or with a history of bruising easily. People should not take aspirin, Aleve (naproxen), Advil (ibuprofen), vitamin E or St. John’s Wort for one week before to 2-3 days after the procedure. Tylenol (acetaminophen) is OK. If people have cold sores, I prefer they are treated and resolved before I inject.

Since the injector is putting a needle through the skin there is the risk of infection, bleeding, bruising, swelling and pain. Typically bruising and swelling subsides in 3-7 days. Infections are exceedingly rare.

The most important factor to prevent complications and to help insure a beautiful result is the experience and track record of your injector. Do your homework. Ask questions. How long have you been injecting? What products are you most comfortable injecting? How do you handle requests for touch ups? What fillers do you recommend for different areas of the face? A good injector should be able to thoroughly answer these questions and more.

Be Well,

Dean M. Tomasello, MD