Drs. Kelly V. Bomer & James Bouzoukis

It is important when placing filler to improve the appearance of the nasolabial folds that cheek volume loss is also corrected.  Much of the depth of the nasolabial fold that we experience as we age is due to volume loss in the cheek, side of face, and under eye which allows the cheek to fall downward thereby deepening the nasolabial fold.  When volume loss in the upper and upper-lateral cheek is corrected first, the resulting lift in the cheek reduces the amount of correction required for the nasolabial fold.  When just the nasolabial fold is addressed with filler the result is often not the desired effect and can lead to an unnatural looking area around the mouth.  Because there is fullness in the nasolabial fold created by the filler, but then none in the cheek, relatively it can look like a new volume deficiency has been created.

In cases where an undesirable outcome from a filler injection persists after the initial swelling has resolved, correction is usually possibly.  If the problem is from too much filler, filler placed too superficially or in the wrong location Vitrase can be injected to dissolve the filler, if the filler is a hyaluronic acid filler such as Juvederm, Perlane or Restylane.  In some cases the best correction may actually require more filler to be placed in adjacent areas to improve the overall contour and appearance.  An expert injector should be familiar with the use of Vitrase and methods of correcting post filling issues.  Expert injectors invariably wind up correcting problems arising from less experienced injectors.

There are a multitude of opinions on this topic. Nurse practitioners definitely have the potential to be a safe option for laser treatments.  In general, I feel it is better if there is an MD who is solely specialized in aesthetic medicine and who is committed to directly overseeing the delivery of aesthetic treatments by nurses, aestheticians and laser technologists in his or her office.

Additionally it is very important that the skin is treated specifically in accordance to the patient's skin type in preparation for the treatment with a prescription skin care program to be followed twice a day for usually at least two weeks prior to the treatment, but more often one month is better.  The skin must also be protected from the sun prior to the treatment without new "color" from the sun.  It is critical that after laser treatments, to heal properly and to maintain the results that the patient is committed to a twice a day strictly prescribed skin care program and proper sun protection indefinitely.

Finally, it is essential not to expect that any one laser treatment of the skin will give all the rejuvenation desired.  When skin laser treatments are performed with the intent to maximize rejuvenation with one or two treatments, one risks injuring the skin forever, creating scar tissue within the skin and/or losing the pigment creating a white waxy "plastic" look.  Although more common with older, full face CO2 lasers, the new technology of high intensity CO2 based Fraxel lasers can also cause these negative results, as well as causing an  unpleasing texture like the surface of an orange if performed aggressively.  With Fraxel this texture change is caused by introducing columns of scar tissue that sit lower than the skin surface that is not scarred, in a pattern that is similar to the Fraxel hand piece pattern, giving an orange peel texture appearance which is irreversible and not aesthetically pleasing.  Skin can also hyper-pigment from laser treatments when the skin has not been prepared properly with prescription skin care prior to the treatment and/or the laser is too hot for the skin type.  If hyper-pigmentation occurs, it often will improve over many months with prescription skin care, but sometimes the hyper-pigmentation that occurs will have a memory and have a tendency toward hyper-pigmentation in those areas forever.

With respect to injectables, it is my opinion that doctors of medicine are qualified if they are truly specialized in the aesthetic field and they have a strong patient following.  Just having an MD at the end of the name does not make a doctor qualified to perform aesthetic treatments.  A qualified MD is one whose practice is specialized in aesthetic medicine and the doctor is commited to the ethics of creating beauty and has a strong patient following.  Performing injectables in an expert fashion requires an intimate knowledge of anatomy, the variation of anatomy between individuals and an aesthetic artistic eye to truly improve patients' beauty.  I do not think nurses have the depth of education required to attain an expert skill level.

It is important to NOT choose who will perform your facelift based on cost.  Facelift techniques vary a great deal from surgeon to surgeon, and your research for finding the right surgeon for you is very important.  You need to be confident that you like the type of rejuvenation the surgeon is creating and that you feel very comfortable with the surgeon's bedside manner.  It is not necessarily a bad idea to travel for a facelift, but there will be added expense for the flight and extended stay.  It is important to stay close to the surgeon until the facelift is healed for at least 2 weeks, but even better is three weeks.

I find that what tends to happen with a limited incision facelift is you are cutting corners and the incision tends to, when you're putting it together, be somewhat bunched and it's not my preference to have a scar that's kind of lumpy initially and then over time it goes down. It's not as elegant a healing process. I find that a little bit longer of an incision helps it to be smoother from the very beginning and heals beautifully. So while it is conceptually attractive to have a short incision, the reality of healing short incisions often is associated with some lumpy, bumpy things that aren't as elegant.

It's so interesting that aging, to a very loose degree, is associated with a number age but it depends on how much you have exposed yourself to the sun, what kind of lifestyle you've led in terms of stress and what you eat. How much you sleep and how much sun you get are the biggest factors that are going to accelerate aging. Regularly I see so many faces and you'd be amazed that somebody is 60 when they look 45 and then the opposite. I have patients who are 38 and look 58. There's not really a number that goes with how aged you look.

It kind of depends on how bad they are, but in general with acne scars it's important to first get control over continuing acne if there is any. The key for that is being on a skin-care program that is focused on intense collagen building. And then a fractionated laser is really great for improving acne scarring. I'm not a fan of some of the more aggressive procedures like full CO2 face laser. I think it's too invasive and can actually add more scarring to the skin. While fractionated lasers are very effective at building collagen and smoothing out acne scars, it is important in my opinion to apply the fractionated laser treatment in a conservative fashion to keep skin looking natural and not waxy or whitened. In my practice we start with a series of three treatments and then wait 4 to 6 months to evaluate the improvement. Collagen continues to repair and fill in the acne scars for up to six months after the treatment.

It really depends on the position of the brows and how low are they. I was recently discussing this with another surgeon who does a lot of fat transfer and I do a lot of hyaluronics and Radiesse but we realized we're both kind of doing the same thing, adding volume to the face. Since we've been doing our respective procedures we're both not doing browlifts nearly as much as we used to. When a brow is lifted too high it actually makes somebody look older. I think a volume-retaining upper lid blepharoplasty gives a better youthfulness to the face so the way I achieve that by retaining the muscle, not removing muscle or fat. For 98 percent of my upper lid blepharoplasties I don't remove any volume, I just remove skin and by pulling the skin together over the muscle you get that volumizing look that is natural.

Dark circles can come from three differing etiologies. There can be brown pigmentation, vasculature showing through thin aging skin and loss of bone at the bony rim under the eye allowing the existing fat around the eyeball to fall forward and appear as a bag with a dark circle shadow underneath.

Treatment:

1. Brown pigmentation: prescription medical grade skin care and collagen building treatments performed at Rejuvent can lift some of this pigment out.  Improving this type of resistant pigment requires daily home skin care and protection from the sun.

2. Vascular dark circles:  In part, this happens to all of us as the skin thins in the delicate under eye area.  Some people, however, are more prone to vascular pigment than others.  The best focus to improve this problem is to thicken the under eye skin with Rx skin care daily targeted to build collagen and moisture content in the skin. Additionally, targeted topical home care treatment is available to diminish the staining of the skin from leaky blood vessels.

3. The precise application of filler in the under eye cheek complex can remove the appearance of bags under the eyes with a dark shadow underneath.  This often requires 2 to 3 treatments for a most improved look as it necessary to proceed with augmentation carefully so that there is not overcorrection which could lead to an unnatural appearance.

There are a lot of skin tighteners. Polaris is a little bit older and there's Nd:YAG. There are ones that involve infrared light or radio frequency. All of them work on the same concept in that they're delivering a controlled injury to the dermis in the form of heat and then the dermis responds to that by laying down new collagen. That can be helpful for improving the quality of the skin and plumping and tightening. To really do all the things we can to maintain our youth and prevent the aging process, the skin tighteners are great. Once we have a lot of aging in place and there's a lot of laxity in the skin, tighteners are really not going to take the place of surgery in my opinion. The aging has to be pretty subtle for a skin tightening procedure to have an effect.

Chemical peels can reduce wrinkles, but one peel, particularly your first one, should not have too much rejuvenation. Peeling the skin can cause permanent damage that is irreversible, so it is important that it is approached with care.  The skin is a delicate and complicated organ, and if injured too severely, it will scar and be changed negatively forever. There is a lot of "rejuvenated" skin in the public that is actually scarred and looks white, waxy and shiny like plastic.  The best results with chemical peels are when the skin has been prepared properly with a prescription skin care program for 2 weeks to 1 month prior to the treatment.  Then peels should be performed every 6 to 8 weeks over a series of months. After 6 peels, one can expect improvement in the wrinkles and pigmentation.  This rejuvenation process is best if continued indefinitely in a like manner to our maintaining clean teeth and gums and exercising our body to keep fit.  It is possible to perform stronger peels with good result, but it is very important not to expect full correction of wrinkles from a strong peel.  If the goal is full correction of wrinkles with any one treatment, often the risk of scarring is very high.  It is important these services are performed in an aesthetic MD office that has the doctor on site who is directly overseeing experienced medical aestheticians or nurses performing the peels.  For strong peels the service should be performed by an experienced MD who is specialized in aesthetic medicine and has a strong patient following.