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Ep. 17: Improving the Skin's Appearance With Expert Cosmetic Procedures

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Ep. 17: Improving the Skin's Appearance With Expert Cosmetic Procedures

Feb 18, 2022

In part III of Skincast's series on cosmetic dermatology, our hosts discuss a variety of cutting-edge procedures offered by board-certified dermatologists to address everything from wrinkles and hyperpigmentation to cellulite and spider veins.


Dr. Tarbox: Hello and welcome to "Skincast," another episode of the podcast for people who want to learn how to take the very best care of the skin they're in. My name is Michelle Tarbox. I'm an associate professor of dermatology and dermatopathology at Texas Tech University Health Sciences Center in beautiful sunny Lubbock, Texas. And joining me is . . .

Dr. Johnson: Hello, hello. This is Dr. Luke Johnson. I'm a pediatric dermatologist and a general dermatologist with the University of Utah. This is Part 3 out of three to four episodes in our series on cosmetics. We had Dr. Adam Tinklepaugh, one of our faculty at the University of Utah, here a few episodes ago. We've got Michelle back here, and we're going to spend today talking about procedures.

So, in a couple of our last episodes, we talked about sort of things you could buy over the counter, maybe stuff that you can have your doctor prescribe. And here is stuff that you can basically pay to have people do to you. And since 70% of my patients are kids, I'm going to lean on Michelle's expertise to talk about a lot of these things.

Dr. Tarbox: Well, there are a lot of different kinds of things that can be done in the office or in a procedural specialty to help improve skin health and appearance. And it starts off relatively straightforwardly and simple with an office procedure called a chemical peel.

Now, chemical peels have been around for a very long time. In fact, the idea of a chemical peel has been around for a very, very long time. There are some writings about how Cleopatra used to bathe in soured milk because it would make her skin softer and more clear-appearing. And what we know now was happening is that some of the acid degradation products of the milk were helping exfoliate the skin, some of the lactic acid and things like that that were in that preparation.

They were used medically for the first time in the 1800s by an Austrian dermatologist named Ferdinand Ritter von Hebra, who actually helped us understand the virus herpes and a lot of things about it.

But chemical peels are one of the first ways that we start to improve cosmesis in the office. A chemical peel involves the application of some kind of chemical substance, usually an acid that's a weak to mild acid that's placed on the skin, and then utilizes what we call the skin's “wound healing response”. And that plays a role in a lot of our regenerative therapies that we can do in the office.

Any time we engage the skin's wound healing response, we can improve cell turnover, we can improve collagen building, we can improve the appearance of fine lines and wrinkles, and also just pigmentation.

But it has to be done carefully because all of us have had wounding to the skin and have had it turn out in not as cosmetically-elegant a way probably as we'd like if we scraped our knee or we fell down and ground our elbow into the concrete. Many of us wear scars to remind us of that. So this kind of procedure does have to be done with care.

But when we do a chemical peel, we evenly apply typically a chemical substance over the surface of the skin we're trying to treat. That causes some level of damage or wounding to the epidermis, and then the skin's natural self-healing mechanisms are triggered, and you get replacement of some of the damaged tissue as well as new collagen synthesis and improved appearance.

Dr. Johnson: Isn't the human body amazing? And especially the skin, of course. It's always pretty awesome when we can use the body's natural procedures in order to achieve results that we're hoping for.

There are a lot of different kinds of chemical peels out there. Some of them are available over the counter, the mild ones, as you might expect. And they can be used for different things. So some of them are used for dark spots, some of them are used for fine lines and wrinkles, and then some of the more intense ones can be used for deeper lines and wrinkles.

Dr. Tarbox: And they're very useful. They have to be used by somebody who knows what they're doing, and the person has to be literate with many different skin types so that they know how oily versus dry or sensitive skin might respond to the peel, as well as different skin tones.

So certain darker skin tones might have a greater risk for hyperpigmentation, where the skin becomes darkened, or hypopigmentation, where the skin looks lighter after the chemical peel if it's done inappropriately in a patient of different skin color. So you have to be careful about selection of therapy for each patient, and each patient should be treated as an individual.

After our chemical peels, we can do something called a Photofacial. You might have heard of Photofacial. That's usually referring to an intense pulsed light treatment. Intense pulsed light is a laser-like device that creates different wavelengths of light for therapeutic targets that can range from pigment, so dark spots on the skin, to vascular, so red areas of the skin, to hair. It can actually help remove unwanted hair with the intense pulsed light.

So those are things that can be done relatively quickly in the office and don't require a huge amount of downtime for light peels. Medium peels will take a little more downtime.

Dr. Johnson: And some of these are fairly inexpensive. I know for some of these cosmetic procedures the price tag can shoot up pretty quickly. But in my experience, the chemical peels and the intense pulsed light aren't too bad.

Dr. Tarbox: And really, when it comes to medical procedures, there are a few things that play into the cost of those procedures. One of those things is the equipment it takes to do that procedure, whether that be an expensive laser, whether that be a consumable product that can only be used once per patient. That has to get factored into the cost.

So, with a peel, the cost is the peeling agent and then the supplies you use to apply the peel. And then we also have price modulation for different services based off of the complexity of the service and the requirement for aftercare.

So things that are what we call the lunchtime facial, the intense pulsed light, or something where the risk is pretty low and the follow-up care is pretty gentle, that tends not to be as expensive as something that takes more product cost, or is more complex to do in the office, or creates greater risk.

As we get to the higher percentages of chemical peels, the more aggressive chemical peels, those might go up a little bit in price. You also have to have more downtime for those more aggressive chemical peels.

Dr. Johnson: You talked about the intense pulsed light devices, a laser-like device. Let's talk about actual lasers. There's a number of them out there, and they tend to be used for different purposes.

A lot of them remove color on the skin, and there are different lasers that target different colors. So, if you've got dark brown spots, there's a laser for that. If you've got pink or red spots, there's a laser for that. And then there are also lasers that just sort of destroy the skin. But again, we can do that in a controlled way to take advantage of the skin's own rejuvenating powers in order to rejuvenate the skin.

Dr. Tarbox: And there are all kinds of lasers. There are what we call ablative lasers and non-ablative lasers. An ablative laser, if you see a picture where somebody's skin is red and it has maybe little white dots on it or it looks very irritated after a laser procedure, that's probably an ablative laser. We call them ablative because they in some way or the other go through the epidermis. So those are laser procedures that are going to require some downtime.

Our ablative lasers can include a CO2 laser. You may have heard of CO2 lasering, like Fraxel. You may have heard of Erbium YAG or Nd:YAG. Those can be ablative as well.

So these are different laser treatments that can wound through the epidermis, which can help engender that wound healing response and improve texture and appearance, but that does require some downtime. And it's a little bit more of a moment, as I like to say, as the patient experiences that laser. So it's a little more intense, but those are really good lasers that can be used to improve skin texture and appearance. The resurfacing lasers, or the ablative lasers, can be helpful in improving skin appearance in a relatively aggressive manner.

Then those ablative lasers can be used either fractionated or fully ablative where they're completely taking out every bit of the surface that they're treating on, or they can be using it in a fractionated way where it's little individual dots across the treatment area, which is going to give quicker healing time and less severe change after the laser. So that's another option.

Dr. Johnson: Poking a bunch of little holes in the skin is how I like to describe it to patients. And it's good for wrinkles. It's good for acne scars. And there's another type of device called a microneedling device that is sort of similar in concept in that it also pokes a bunch of little holes in the skin. But instead of using lasers, it uses little needles.

Dr. Tarbox: So a lot of what we do is controlled wounding of the skin where we're actually using a tool of some kind of, be that a laser, be that a microneedling device, to in a controlled way use the wound healing capacity of the skin to improve its health and appearance. So those are other ways you can handle that.

Microneedling can be used to improve acne scars. It's very good for that. It's also used to improve texture of skin on the face with fine lines and wrinkles. It improves discoloration. It also improves some of the scarring that can be left behind after an inflammatory process.

And microneedling can be used to introduce different medications to the skin. It can also be used with platelet-rich plasma or used to help improve hair growth at home. So there are lots of options with microneedling.

It can also be used with radiofrequency, where the microneedles themselves actually have radiofrequency energy that goes through them and bulk heat the tissue in another way to wound it to help improve the appearance, and texture, and turgor of the skin, meaning it gets tighter.

Dr. Johnson: Some of these microneedling devices are available over the counter. If you were to want to purchase one of those and use it, just make sure you follow the instructions, because if you don't know what you're doing, you could perhaps end up in trouble.

I think it's useful to know that in a lot of these procedures, microneedling and laser and stuff, you often need multiple treatments before you get the full results that you're hoping for. So, for example, in microneedling, it probably takes four to six total treatments to get the results that you're hoping for. So, if you're planning to do something like this, go into it with that in mind. The procedures are usually something like four to six weeks apart.

So what if it's not my face that's the problem? What if I've got spider veins or varicose veins in my legs? Can dermatology help?

Dr. Tarbox: So, for spider veins in the legs, there are lots of different ways that dermatologists can be beneficial. One of the ways that's more straightforward is our sclerotherapy treatment. So sclerotherapy actually involves the use of a medicine that is injected into the tiny vein that is broken. So we're actually injecting into the lumen of the vessel.

It's kind of like a fun skill game for dermatologists. I don't know about you, Luke, but when I'm doing sclerotherapy, I think that I understand people who play video games compulsively because of the sense of reward I feel when I actually get one of those little blood vessels cannulated. And then I see that whole mat of those broken blood vessels just blanch out as the medicine goes through them.

And what the medicine does inside the vessels is it makes the walls of those teeny tiny blood vessels that we don't use for anything . . . They're just there because we have usually a broken valve in a vein or something. Those little tiny vessel walls get sticky to themselves, so they kind of close down on themselves. And they don't have blood circulating through them anymore, so you don't see them on the surface of the skin.

And because these are basically dead-end, useless tributaries that we don't need for anything else, there's no damage to the patient by treating these. It just improves the appearance, and sometimes if there's pain associated, it improves the pain.

Dr. Johnson: Dermatologists could treat some of the little to medium type veins, I would say. If you've got a big old varicose vein, then it might need a vein specialist.

Dr. Tarbox: Yeah, vascular surgeons might be the right place for those big veins. Some dermatologists do the endovenous laser ablation. Some don't.

Dr. Johnson: What about body contouring?

Dr. Tarbox: So liposuction was actually developed by dermatologists. The person who invented liposuction was trying to find a way to treat lipomas, which are those little fatty tumors that some patients get. And so he sort of conceived of a device that was like a suction needle you could put into the lipoma and remove it that way.

We don't really use liposuction to remove lipomas, but it is used for a lot of body contouring and shaping. And it does fall within the purview of dermatology. A lot of dermatologists do liposuction. I was trained to do it when I was a resident, and it can be very useful.

Dermatologists can also use liposuction to obtain fat for fat grafting, which is a procedure that can be done to help improve areas of volume loss on the face or help improve a scar cosmesis following reconstruction.

Dr. Johnson: In recent years, there have been other devices that have been developed that have taken advantage of other technologies and other aspects of physics in order to perform this body contouring. They have names like CoolSculpting, and then there are also radiation ultrasound-type devices that can potentially perform some of these actions.

I'm not super familiar with them since I don't do a lot of cosmetics. How do you feel about these, Michelle?

Dr. Tarbox: So they don't not work. The gold standard is liposuction, where a cannula of some variety is inserted under the skin and is passed through the fat layer either mechanically through the arm motion of the operator, or ultrasonically through a sonic oscillation of the cannula itself that can withdraw the fat cells from the patient's body.

There are other things that are also using the fat's vulnerability areas. So our fat is more vulnerable to cold than other parts of our body. There's a kind of condition that often will happen with toddlers, where they get a popsicle and they just sort of let it sit on the face while they're enjoying it, called popsicle panniculitis where the fat actually dies because of the exposure to sustained cold.

And that's the premise for CoolSculpting, which I have tried to see what it was like. It is a doable procedure. It's not completely uncomfortable, but it is not pain-free. So you need to be aware going in that it's going to require a little bit of mental toughness to go through.

But CoolSculpting is based off of that popsicle panniculitis or that cold panniculitis property of fat where fat does not tolerate very low temperatures for prolonged periods of time.

When they do CoolSculpting, they apply a little gel matrix pad to the skin that is to protect the epidermis from the freezing so you don't also get frostbite of the skin. And then they use a sort of suction probe to suction part of the area of adiposity they want to treat into the treatment handle, which can then cool down and basically freeze that part of the fat that is being subjected.

And then once they remove the suction device, the fat is still frozen. When they do it on the abdomen, it makes something called a butter stick. So it's about that size. It's just frozen solid fat. Then the esthetician or the person doing the therapy for you has to massage all of that out to kind of break it apart, which does two things. It sort of mechanically agitates some of the fat cells that are already frozen, and that can break them up, which kills them. It also helps prevent there being any kind of focuses of increased damage because of temperature irregularity. So that's CoolSculpting.

Dr. Johnson: There are a number of other products out there that exist for specific purposes that have reasonable medical data to support them. So, for example, what dermatologists call submental fullness, or sort of a fatty under-chin or double chin, there's a product that you can inject that'll dissolve the fat and help it tighten up. The brand name is Kybella.

Dr. Tarbox: It's bile acid. It's just bile acid going into the skin. That also hurts. That also is a painful procedure.

Dr. Johnson: But it seems to work all right.

Dr. Tarbox: But it works. It does work.

Dr. Johnson: If you have cellulite, especially on the butt, there's a new product out there that has collagenase, which is a protein that will dissolve collagen, that has some efficacy behind it. I believe the brand name is QWO.

And then plastic surgery is, of course, its own surgical specialty and they can do all kinds of stuff to your face. Some dermatologists do some plastic surgery.

And then we didn't really talk about Botox, or more generically botulinum toxin injections, or fillers. I think we've hit those in some of our previous podcasts. I think the short answer is that Botox . . . both Michelle and I are big fans of these botulinum toxin injections, and I think you'd heard Adam Tinklepaugh talk about them too. I like them. They tend to over-perform. They're good for wrinkles, especially rather small, rather shallow ones.

And then fillers add bulk to areas where you don't have bulk. So some people prefer to have more luscious-looking lips, for example. And then other people, perhaps because of the normal aging process, have just lost some of the subcutaneous fat in certain areas of their face, and filler can replace those.

That's my quick and dirty thoughts about those, Michelle. Do you have any thoughts that are slower and cleaner?

Dr. Tarbox: I really think Botox is a great treatment for facial wrinkles. Dysport and Xeomin are other types of neurotoxins that are similar to Botox. And they also help improve the appearance of the skin as well as decreasing unwanted facial movements.

There are studies that show us that we've reviewed on our other podcast, the more scientifically-based longer podcast that we do called "Dermasphere" . . . We've discussed the fact that long-term use of Botox actually improves brow position. So it helps improve the way the face ages over time. And it helps improve also some aspects of skin texture, so you have finer poor appearance often in areas that have been treated with Botox.

The fillers, there are a lot of different fillers. There's the Restylane product line. There's the Juvederm in product line. There are HA fillers. All of these definitely are usable in a different way to fill volume deficits, to improve tissue building, and to deal with lines and expression changes that happen over the face.

They should be used by somebody who knows what they're doing, because they are not without risk if they're done incorrectly or if there is just a day of really bad luck. People can have the filler get into a blood vessel accidentally, and that can either cause some part of the tissue that's supplied by that blood vessel to die. That's called necrosis, not something that you would want to have happen to you. Or in extreme cases, it can cause blindness. So they do need to be used by somebody who knows what they're doing and has been trained to select the right location and the right filler to use. And of course, they should only be done by medical professionals in a safe and clean environment.

Dr. Johnson: And that wraps up this three- to four-part series of cosmetics, but we might talk about cosmetics more later. Who knows? There seems to be a lot to talk about.

Thanks for hanging out with us today. Thanks also to the University of Utah for supporting the podcast and to Texas Tech for lending us Michelle.

And as Michelle alluded to, we have another podcast that's scientifically nerdy. It's called "Dermasphere." It's intended for other dermatologists and the dermatologically curious. And if you consider yourself dermatologically curious, come check that out. Otherwise, stay healthy, beautiful, and handsome, and we will see you next time.