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Aesthetics Practice Today

An Exciting 20 Years
February 4, 2016 11:18 AM by Mina Grasso
It is exciting to reflect back over the past 20 years on the evolution of non-surgical aesthetics in our practice.   Non-surgical aesthetic procedures now address fine lines, wrinkles, volume loss, irregular pigment, loose skin, veins, tattoo and hair removal, scar reduction, body contouring for fat and cellulite. In our practice we have incorporated bio-identical hormones and sexual health now to include vaginal rejuvenation.   A majority of these concerns patients have presented with are related to aging and hormones and an ongoing endeavor of anti-aging secrets to optimize beauty and vitality.  The following are a few highlights in the aesthetic trends in our practice.

"Injecting poison in your face?" Although still feared and avoided by many, Botox, initially was referred to, as a "poison" is now a more common household word. It becomes beauty maintenance for those who have experience the benefits, just as getting their hair colored or their teeth cleaned. Botox, Dysport and Xeomin are neuromodulators available in the US used to relax dynamic muscles that create wrinkles and even prevent wrinkles by blocking active contracting muscles. From what one patient may have feared Botox as a "poison" she didn't want in her face to "going to her Disneyland" when she comes in for her Botox or Dysport.

Liquid Facelift with soft tissue fillers: In the late 1990s some patients took advantage of bovine-based collagen injections to fill fine lines and wrinkles.  Patients who desired this had to undergo skin testing one month prior to treatment to test for allergy to bovine collagen. A great percentage of patients loved their results, however dissatisfied with the 3-month longevity of the product. In an effort to provide products that would last longer, cadaver particles, silicone and various other ingredients have been used to fill soft tissue as an alternative to fat transfer and surgical facial implants. 

Liquid Facelifts became more of a concept when Restylane, a non-animal based hyaluronic acid was FDA approved in the early 2000. Other products in the Restylane family were developed then the Juvederm family of products was introduced soon after. Radiesse, calcium hydroxylaptettit, tissue filler as well as a bio-activator was introduced soon after these products. Results of these products would be experienced immediately.  For those who were not needing immediate results and were enamored by the idea that their own collagen could be stimulated, Sculptra, poly-l lactic acid gained popularity. As new products were introduced, we continued to learn more about volume loss and the aging process. Skin changes, fat shrinkage and redistribution as well as bone loss were better understood in the aging face. 

We have evolved from chasing fine lines and wrinkles to a more global approach, understanding that a youthful face is more a triangle of beauty vs. the squared, aged look. The phi theory of proportions is used as we restore and enhance beauty. 

Non-surgical "liquid facelifts" are popular worldwide. It was surprising to see the term now offered as a medical spa service on cruise ships. 

Non-ablative, no downtime laser and light technologies: 20 years ago, non-ablative laser and light technologies were just being developed and we familiar with what was out there. Intense pulsed light (IPL) was our first non-ablative device is still one of the most popular technologies. Since then various non-ablative lasers using various wavelengths treating specific issues of the skin such as redness, broken capillaries, large pores, irregular texture and pigmentation have come to market. We as well as our patients have observed age reversing appearance of the skin. There was a study that actually proved to show via skin biopsies more youthful gene patterns of skin treated with a broadband light device vs. non-treated skin. Patients can benefit from anti-aging treatments over time with non-ablative technologies.

Minimally ablative laser procedures: No one likes downtime, but those who were willing to sacrifice 5-7 days of social downtime have experienced more dramatic results with certain minimally ablative lasers such as our lasers that target small veins on the face and pigmentation. For skin texture and rejuvenation, fractional non-ablative Fraxel was very popular. Some patients had more downtime than expected.

A few years later, we started to offer a minimally ablative fractional CO2 laser resurfacing to treat acne scars, surgical and traumatic scars and for general skin rejuvenation. We found that patients that although patients looked more red and swollen the first couple days, we had fewer side effects such hypo or hyperpigmentation, minimal to no acne breakout post procedure. Patients tolerated the procedure better with less discomfort. All skin types can be treated. We experienced higher patient satisfaction, improved results with fewer side effects. Fractional CO2 laser resurfacing is our go-to laser for those seeking more dramatic results for skin rejuvenation.

Skin Tightening: Over the years several technologies to treat various concerns for the face and body have been developed. Cellulite was one of the most challenging to improve. Endermologie, a cellulite solution using mechanical massage based on lymphatic drainage improved the appearance of cellulite temporarily. We still have patients who have experienced the benefits of Endermologie till request the treatment. Over the years, laser and radiofrequency energy was found to enhance the effects of mechanical massage and Velasmooth, Tri-Active and Viora Reaction were introduced to the practice. These devices offered temporary relief of cellulite after a series of t1-2 times a week sessions. The most recent addition for cellulite is ThermiTight RF injectable radiofrequency offers a longer 1-2 year solution to cellulite after one session. 

We have addressed skin laxity in the face and body with Thermage and Viora radiofrequency without downtime. Now a minimally invasive temperature control system utilizes higher energy levels of radiofrequency and provides longer lasting results. Injectable RF - ThermiTight can address skin laxity in the jowls and neck, arms, abdomen, thighs and loose skin over the knees. Radiofrequency triggers neocollagenesis, which helps firm, tighten, lifts and tones the skin. Higher temperature range can produce more neocollagenesis.

Body Contouring and Fat Reduction: Laser lipolysis with small areas of liposuction were performed years ago. We abandoned this to meet our patient's demand for no downtime options. Coolsculpt technology utilizes cryolipolysis to freeze fat cells. Fat cells are destroyed controlled freezing of fat using a specific applicator for the area treated. Cryolipolysis results in apoptosis of fat cells. Initially we had an applicator only for the small areas of the abdomen. Over time specially curved shaped applicators to treat the love handles and back fat as well as larger applicators for larger areas of the abdomen were made available. Several years later an applicator for saddlebags became available as well as a smaller applicator that we can use for inner thighs, upper arms, anterior and posterior axillary fat.

Before the end of 2015 a long-awaited applicator, the Coolmini, was brought to market. It was developed to treat submental fat. The "double chin" is a concern for approximately 67% of all aesthetic patients.

This year, 2016, brings another promising solution to the "double chin" fat. Kybella (deoxycholic acid) is a chemical ingredient we used in our mesotherapy formulation to dissolve fat for various areas of the body years ago. We, like other practices, abandoned the practice of mesotherapy. Our reasons included lack of standardizations of recommended formulas, severe bruising and swelling. Skin necrosis had been one of the worst adverse events we encountered. Kybella is standardized and specific protocols have been developed for safety and efficacy. We have experienced great results and are proud to offer this minimal to no downtime solution for the "double chin."

Anti-Aging: For decades people have searched for various anti-aging remedies. Skin care, peels, laser have claimed to produce age-reversing results. Platelet rich plasma (PRP) has created quite a buzz during the past decade. PRP utilizes a patient's own plasma to regenerate and repair exposed tissue. We commonly apply the PRP immediately after procedures such as Dermapen (microneedling) and fractional CO2 laser resurfacing.

As part of an aesthetic practice we have incorporated bio-identical hormones (BHRT) and nutritional counseling. Nutrition and hormone balance plays a big role in overall skin health and vitality.

In providing hormone therapy, sexual health issues are frequently discussed. The most recent aesthetic procedure added to the practice is ThermiVA, a non-surgical, no-downtime vaginal rejuvenation that utilizes radiofrequency to tighten skin laxity of the vulva, and when used in the vaginal canal results in tightening of muscles and increases vaginal lubrication as a result of thermal neurogenesis. Patients report improved issues with incontinence and sexual health. 

The evolution of our aesthetic practice over the past 20 years truly has been patient driven. Patients seek and benefit from anti-aging, non-surgical, minimal to no downtime procedures that fit their busy lifestyle.

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Skin Quality Improvement
January 19, 2016 8:18 AM by Mina Grasso
Skin quality improvement can be accomplished in a variety of methods. Skin is the first line of beauty. It is one of the first clues to our age and general health. Skin hydration, reflection of light, tone, texture, pigmentation, fine lines and wrinkles can be addressed with specific therapeutic, cosmeceutical and prescription skin care ingredients to enhance the health of the skin. Combined with laser and light technologies and/or chemical peels, skin quality can be further restored. As we continue to age and our skin is subject to environmental factors such as sun exposure, changes in humidity, free radicals and hormonal shifts, maintenance is required. Prevention and protection such as minimizing exposure and routine use sun protection and antioxidants in skin care are key to giving us the best chance to maintain the beneficial results.

Skin tightening for laxity can be addressed with non-surgical skin tightening procedure using radiofrequency technology (Thermage, Viora) or ultrasound technology. ThermiTight Injectable RF a minimally invasive procedure involving controlled, but higher energy radiofrequency delivered under the skin can address skin laxity for the jowls and neck. Those with more severe laxity seek surgical options out.

Volume loss replacement can be addressed using a global approach. The entire shape of the face changes due to fat loss or redistribution, bone changes and skin factors as mentioned above. Tissue fillers and collagen stimulators help to address and restore facial shape and fullness that are associated with a more youthful face. 

Tissue fillers commonly used include, but not limited to hyaluronic acids in the Restylane and Juvederm family. Radiesse, calcium hydroxyapatite, is both a soft tissue filler and collagen stimulator.

Sculptra, poly L-lactic acid, is a very safe product that is often used in implants and dissolvable sutures. Sculptra promotes production of natural collagen in the treated areas. Sculptra gradually corrects the recession of the skin or adds volume to areas of bone loss such as around the cheeks, temples chin and along the jawline. Sculptra is used to volumize and provide structural support. Sculptra creates a scaffolding of collagen with long-lasting results.

Natural proportions of a beautiful face can be refined and restored with volume replacement. Facial volume can help maintain the triangle of youth while the aging face normally would descend to a more square shape with aging redistribution of facial structures.

Fat Reduction in the Neck

In aesthetic surveys, 67% of consumers are bothered by submental fat. Patients look and feel older with greater fullness in their neck. Kybella is the first and only FDA-approved nonsurgical treatment that contours and improves the appearance of submental fullness. Kybella (deoxycholic acid) is a solution used to treat moderate to severe fat submental fat. When Kybella is injected into the neck fat, it physically destroys fat cells. Multiple injections are used in a single treatment session. Kybella is a simple in-office procedure that typically takes as little as 15 to 20 minutes may be required for desired results

CoolSculpt CoolMini - Cryolipolysis has been an effective non-invasive method that has been used for several years to sculpt the body by destroying fat cells by freezing the fat under a carefully controlled condition. The neck skin and fat is sucked into a small chamber for an hour while the fat is treated with controlled freezing. Apoptosis is focused directly at selective fat cells while preserving the surrounding skin. "Prolonged, controlled local tissue cooling can induce selective fat cell reduction and subsequent loss of subcutaneous fat, without damaging the overlying skin".

Develop a Maintenance Plan for Facial Rejuvenation

Many of these procedures work synergistically. Multiple sessions may be required for the desired results. Continued treatment can develop cumulative effects. As a result patients can look more youthful today than they did 5-10 years ago. With increasing sophistication in clinical photography we are becoming more aware of the secrets that are refining, restoring and reversing the signs of aging.
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What’s Hot in 2016
January 5, 2016 1:50 PM by Mina Grasso
Aesthetic concerns of women go beyond the face and common body treatments.  Over the last decade focus on the body with term "Mommy Makeover" has increased in popularity. This year women will seek solutions to restore feminine youthfulness. "Vaginal Rejuvenation" has entered the world of aesthetics. The topic is gaining awareness worldwide.

Many don't bother reporting issues because they have accepted it as part of the aging process. Others due to cultural reasons are horrified to consider discussion or deny they have any issues. When bringing up the topic usually with their GYN practitioner, overactive bladder and stress incontinence are usually more acceptable topics to start the discussion. This may lead to discussion of vaginal laxity or looseness and other vulvovaginal issues like atrophy lack of lubrication - dryness especially in the perimenopausal and menopausal ages. Orgasmic disorders and sexual desire are issues rarely brought up by patients largely due to acceptance with aging and hormonal decline. Family practice, women's health and other specialties and now the world of aesthetics can provide options for treatment to optimize sexual health.

ThermiVA is a revolutionary solution to restore feminine youthfulness for our patients who desire cosmetic enhancement of the vulva and have experienced the additional benefits of resolving their incontinence and have reported improved orgasms. 

ThermiVA is a non-invasive procedure that requires absolutely no downtime. It utilizes a controlled radiofrequency platform. A small applicator with a temperature sensor at the tip is used to heat the tissue of the vulva and the vaginal canal. It uses temperature as a clinical endpoint to smooth skin and shrink mucosa. Heating the skin and mucosa promotes immediate contraction of collagen, immediate collagen remodeling and elasticity, and long term stimulation in producing new collagen. It is believed that incontinence and tightening of the pelvic floor and the heat of the radiofrequency to stimulate neuromodulation improve sexual function.

ThermiVA is the current WOW of the practice. Patients describe the procedure with the sensation of a hot stone massage on the vulva and report a pressure sensation with virtually no pain in the vaginal canal. No pain medication or anesthetic is required. With more patients demanding non-surgical options that provide long-lasting results without downtime, patient satisfaction is extremely high.

Patient testimonials:

"I am a 65 yr old woman that had experienced a decrease in sensation during sexual activity. My orgasms were lackluster if they even occurred. I heard of the ThermiVa procedure and had my first treatment 7 weeks ago. It was a short and comfortable procedure in a most aesthetic environment. There is no down time with this procedure so was anxious to see results.  All I can say is "WOW." All of my vaginal nerve cells came alive. It was like having intercourse 20 years ago. A few weeks ago, I had the second procedure with this treatment. I noticed tightening of both the external labia and vulva. The sensation is phenomenal and I am truly satisfied."

"Walking, laughing, sneezing, coughing frequently caught me in the embarrassing situation of uncontrollable dribbling. After the 1st of 3 ThermiVa treatments the improvement was surprising. I didn't expect results to occur within hours of the procedure, but they were. I'm able to "clench" and stop mid-stream (just as a test).  The month after the 1st treatment has been a relief from worry because I know I can control and prevent leakage."

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Scalp Micropigmentation
December 22, 2015 9:18 AM by Mina Grasso

Hair loss can be devastating to anyone at any age. Image is so crucial in the society that we live in.  The devastation of hair loss affects self-esteem and self-confidence. Men and women suffer from this life-changing experience and go through psychological stages with shock, denial, anger, depression and acceptance just like emotions that occur after a traumatic experience.

Trying to hide hair loss goes way beyond wearing a hat. Those who suffer with hair loss constantly search for solutions from hair systems, lotions and potions to hair transplant. For some, it can become an obsession.

Concealing methods can involve tedious time-consuming daily routines that can change lifestyle and sociability.  Hair systems require a significant amount of maintenance and money monthly to keep a particular look.  These individuals suffer because they cannot exercise or shower frequently, because the bond used to keep the hair system on will deteriorate if moisture is introduced.

Scalp Micropigmentation

Scalp micropigmentation, also known as SMP, is a great hair solution for those who suffer from hair loss or are left with visible scars from hair transplant surgeries. If done correctly with a well skilled technician, amazing results can be obtained that can improve the quality of life of suffering individuals.

The permanent makeup industry has evolved with new pigments, tools and techniques within the last few years. I have been involved with permanent makeup the last 20 years, but have seen more advances in the recent past. Earlier in the year I wrote about advanced eyebrow tattooing with the use of a manual tool; however, permanent makeup has also found its way into a possible option for those who suffer from hair loss. SMP is a permanent makeup procedure that provides the appearance of a hair follicle on the scalp.

Scalp Micropigmentation vs. Traditional Permanent Makeup

Scalp micropigmentation is not necessarily a new service; permanent makeup artists have attempted addressing the scalp area in the past. Different from traditional permanent makeup pigments, the pigments usually used for scalp micropigmentation do not contain iron oxide, which can be metabolized by the body. Those who have had permanent makeup are very aware that over a few years the color may change from its original color. Pigments usually used in successful scalp micropigmentation are charcoal based, which is not metabolized by the body. However, these charcoal pigments can turn to an ashy color if routinely damaged by UV rays. So, the daily use of SPF is recommended for those who opt for this type of procedure.

Artists who would attempt scalp pigmentation using traditional permanent makeup techniques on the scalp usually resulted in deposit of pigment too deep into the dermis. Depositing pigment deep in the dermis creates an image of a splotch rather than the look of a hair follicle due to the pigment migration from its original location. Specialized training is required for scalp micropigmentation technicians. The pigment must be placed specifically in the epidermis. The tools used in scalp micropigmentation are different than those used in traditional permanent makeup. The needles that are used are modified to replicate the look of a hair follicle, rather than the dot that is left behind by traditional needles.

Just as permanent makeup has provided a timesaving convenience for many as well as an improved image, I anticipate that patients who suffer from hair loss will experience a change in behavior, personality, self-esteem and self-confidence in their personal and professional lives.

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How to Choose a Double Chin Solution That’s Right for You
December 8, 2015 10:25 AM by Mina Grasso
Women often report that they hate photos of their double chin when caught by surprise when their child takes their photo with their smart phone or ipad. This year much focus has been on aesthetic procedures to deal with one of the most common complaints. Millions of people are bothered with - The Double Chin. In aesthetic surveys, 67% of consumers are bothered by submental fat.

When considering treatment for double chin, the following are discussed to guide patients in choosing the option that best meets their goals:

  • Amount of fat in the neck
  • Amount of loose skin
  • Social downtime
  • Cost
  • Number of treatments recommended
  • Expectations and results

The three non-invasive to minimally invasive solutions popular in 2015 include:

  • ThermiTight Injectable RadioFrequency
  • CoolSculpt Freeze Fat with Cool Mini
  • Kybella an injectable solution to melt fat.

ThermiTight Injectable RadioFrequency

ThermiTight RF is considered the "in-between" for those patients wanting more results that current non-invasive procedures can provide, but do not want to undo go surgery.  ThermiTight is minimally invasive aesthetic procedure that delivers controlled thermal energy. After local anesthetic if applied, a small radiofrequency probe is inserted under the skin. The radiofrequency probe is passed under the skin as the tissue is taken to its target temperature.

An infrared camera is used to monitor the temperature of the skin externally to provide accurate energy delivery while avoiding excessive heat that may result in damage to the tissue being treated.   

ThermiTight RF is used to treat the jowls and neck for fat reduction and skin tightening. Specific temperatures are used for melting fat as well as skin tightening. It is considered to be a one-time treatment, however some patients may choose to repeat the procedure to improve results or wait several years. The treatment time required for the jowl and neck is usually 30-45 minutes.

Some improvement may be seen after a month and continue to improve over time. Daily activities can usually be resumed after 24 hours. Patients may experience minor swelling 2-10 days. Thermitight RF can treat mild neck fat, but the primary focus is skin tightening.

The cost of ThermiTight RF for the jowl and neck is approximately $3,000-3,500 as a one-time procedure. The latest "worth it ratings' on RealSelf reviews rated ThermiTight RF as "94% worth it" (59 reviews) for that last 24 months.

CoolMini - Coolslculpt Using Cryolipolysis to Freeze Fat

Cryolipolysis has been an effective non-invasive method that has been used for several years to sculpt the body by destroying fat cells by freezing the fat under a carefully controlled condition. The neck skin and fat is sucked into a small chamber for an hour while the fat is treated with controlled freezing. Apoptosis is focused directly at selective fat cells while preserving the surrounding skin. "Prolonged, controlled local tissue cooling can induce selective fat cell reduction and subsequent loss of subcutaneous fat, without damaging the overlying skin." This year the Cool Mini was introduced to treat smaller area bulges like the submental area - neck fat.

Inflammatory cells digest the treated fat cells, and the fat cells are gradually eliminated by the immune system, reducing the thickness of the fat layer. On average patients can experience a 20-25% fat reduction of the fat sucked into the chamber, consistent with other CoolSculpting applicators.

No needles, no surgery and no downtime. Minor swelling may be experienced for a couple days. Numbness and tingling may be experienced for approximately 2 weeks. Patients resume regular activities immediately. Eighty-three percent of patients were satisfied with their results. This is a favored procedure with very mild to zero social downtime.

Two sessions with one cycle are generally recommended, six weeks apart. Patients with larger neck fat may require more cycles and more sessions. Each cycle is one hour long. The average cost per cycle is approximately $1,000. Packages of cycles are usually available.

There is no Real Self worth it ratings on Cool Mini yet. Studies showed 83% satisfaction rate. Overall Coolsculpt for various body parts reveal "worth it ratings" (1463 reviews) resulted in 72%.

Kybella - Injections to Melt Neck Fat

Kybella (deoxycholic acid) is a solution used to treat moderate to severe fat submental fat. When Kybella is injected into the neck fat, it physically destroys fat cells. Multiple injections are used in a single treatment session. 

Topical anesthetic may be applied prior to the injections. Some patients experience discomfort following injection. Oral pain medication can be taken for comfort. 

Depending on the fat volume treated and the amount of solution used usually determines the amount of inflammation that occurs post procedure. Usually the more fat volume treated the more inflammation. Some have referred to severe swelling as "bullfrog" appearance. Swelling can result in more social downtime, which may last 2-4 weeks. Smaller volumes may induce very little swelling and less social downtime.

The most common side effects of Kybella include swelling, bruising, pain, numbness, redness and hardness in the treatment area.

Depending on the amount of fat volume, one to six treatments may be required. Treatment sessions are usually six weeks apart with an average cost of $600-$1,200 per session. The latest "worth it ratings' on RealSelf reviews rated Kybella as "100% worth it" in 42 reviews for that last 24 months. 

Evaluation by a healthcare provider who is knowledgeable in different options for treatment of the double chin is crucial to evaluate amount of neck fat and loose skin. Options can be discussed involving amount of social downtime, cost, anticipated number of treatments, frequency and realistic expectations.

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Appearance of Double Chins
November 23, 2015 5:52 PM by Mina Grasso
This year the hottest aesthetic procedures seem to be focused on the neck. The most frequent digital photos deleted whether taken by another person or a selfie usually revealed an undesirable angle of neck. Double chin, loose turkey neck, neck fat and lack of jawline definition is usually are the complaints of an undesirable neck. 

We introduced ThermiTight Injectable RF for skin tightening last year. Patient awareness increased with TV media and the Internet with online reviews and YouTube. ThermiTight Injectable RF in a minimally invasive skin tightening procedure that utilizes controlled heat and an innovative skin temperature monitoring system that allows us to provide consistent heat using specific protocols therefore consistent results, safely. ThermiTight Injectable RF is usually recommended as a one-time procedure. Some patients are experiencing results up to three years.

Coolsculpt utilizes cryolipolysis to freeze fat on various parts of the body where unwanted fat bulges have developed. Last month a smaller applicator called CoolMini was introduced to treat neck fat. Mild swelling may occur. Minimal to no downtime is required. One to two treatments are usually required depending on the amount of fat to be treated.

Kybella was also introduced this year for treatment of neck fat. Kybella is a simple office procedure that requires injection of various points on the neck to dissolve fat. Patients may experience swelling in the area treated for 2-4 weeks. So, this procedure requires a bit more planning. The advantage to using Kybella is that areas that cannot be treated with Coolsculpt due to the applicator shape and size can be targeted directly with injections.

The benefits of ThermiTight Injectable RF, CoolSculpt with the CoolMini as well as injections with Kybella will not be experienced immediately. It usually takes a few months to see the improvement and usually continues to improve for several months

As we treat neck fat and reduce volume in the neck, we find that the platysmal band muscles become more prominent. The procedures above do not address treatment of the platysmal bands. Patients are made aware of an option that has been available for over a decade that involves using a neurotoxin such as Botox or Dysport to relax the tight platysmal bands. Relaxing platysmal band muscles results in a more youthful and attractive defined jawline. This treatment alone happens to be one of the favorite places patients request Botox or Dysport. Results are experienced with one to two weeks.

One or a combination of these hot aesthetic procedures for the neck can result in a more youthful and attractive defined jawline with reduction of fat, tighter skin and relaxed platysmal bands. Enjoy more of those family photos and selfies without feeling the need to delete ones showing your neck.

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Anti-Aging Benefits of Relieving Bruxism
November 10, 2015 10:27 AM by Mina Grasso
Do you awaken with sore jaw muscles especially after a stressful day? Bruxism is a condition in which you grind, gnash or clench your teeth. Bruxism can occur unconsciously with clenching of your teeth together during the day or clench or grind them at night (sleep bruxism).

Many suffer from bruxism and don't realize that a multitude of problems, including premature aging of the jawbone can occur over time due to chronic grinding and clenching. Wear and tear of the jawbone breaks down structural support and can lead to dental issues. Loss of approximately 30% of the upper and lower jawbone can occur. Volume loss related to bone creates hollowing of the lower chin, jaw and creates folds and wrinkles. This volume loss creates a more "aged" appearance.

Untreated bruxism can lead to soreness of the jaw, migraine headaches, neck and shoulder pain, vertigo and ringing in the ears.

Patients with bruxism are usually noted to have hypertrophic (enlarged) masseter muscles, which makes the shape of their face appear squarer. In the aesthetic world, we aim for a more tapered, angular "triangle of youth" appearance. 

Neuromodulators such as Botox, Dysport or Xeomin injections can help alleviate symptoms of bruxism by relaxing the masseter muscles. These neuromodulators can relax the muscle so clenching is not so forceful. Treatment of hypertrophic masseter muscles involves a simple office procedure where targeting specific masseter muscles can be injected with doses of approximately 15-20 units on each side of the jaw.

Neuromodulator injections of larger masseter muscles are used commonly in Asia for reshaping the face to be more angular rather than square. Larger masseter muscles may require 20-30 units in order to change the shape of the face.

Successful treatments result when the practitioner is familiar with the functions of the facial muscles and can isolate the specific masseter muscles for injection.  Extreme care must be taken to avoid injection into surrounding muscles, which can result in undesirable appearance. 

Injection of the hypertrophic muscles should alleviate symptoms of the grinding and clenching. Sometimes the temporalis muscles of the temple need to be treated, which are involved in mastication, in order to relieve symptoms.

Bruxism is an important condition to treat in order to prevent a multitude of problems. The treatments are simple and cause no downtime. Most important in men and women treatment can prevent premature aging of the jaw as well as preserve jawline teeth, bone and a youthful appearance.

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ThermiTtight
October 27, 2015 4:54 PM by Mina Grasso
Fit and motivated women who spend hours in the gym doing cardio, firming, toning, get upset when they see loose wrinkled, crepey skin that ripple over the top of their knees in the mirror as they reach for a set of weights. Women often comment that this is one of the areas that drive them crazy, because no matter how much they diet and exercise the wrinkled skin over their knees does not go away.

Our skin undergoes several changes as we age. It becomes thinner, drier, and less elastic with the collagen breakdown compounded with the effects of accumulated sun exposure. Hormonal decline also contributes to loss of collagen and elasticity.  Wrinkles and loose sagging skin become more apparent with time. Women often restrict their wardrobe choices in order to hide sagging, wrinkled skin on their knees that make them feel older. What can we do to get that skin to snap back?

In non-surgical aesthetics, much attention has been focused on the face and neck. In the last few years more attention is paid to tightening various parts of the body. Women want to know - what about the knees? Various non-invasive technologies are well tolerated and require no downtime. Multiple treatments can help stimulate collagen production and skin tightening modestly. External radiofrequency such as Viora refit and Thermage cause collagen fibers to shorten, contract and tighten. Viora Refit requires a series of treatments while Thermage is recommended annually. Results vary between individuals with low to high satisfaction rates. Higher satisfaction rates have been reported with a procedure that utilizes injectable radiofrequency. 

Injectable radiofrequency is performed with ThermiTight RF is a micro-invasive procedure and requires minimal downtime. ThermiTight RF is the first aesthetic procedure that delivers safe controlled thermal energy. A radiofrequency electrode is inserted under the skin after local anesthetic is administered. Radiofrequency energy is then applied to the tissues stimulating contraction of the skin.

ThermiTight tightens skin to a much greater extent than any other energy based technology. In addition, small areas of unwanted fat can be melted during the procedure, which aids in contouring the area treated.

After local anesthetic is administered, depending on the area treated, the procedure may be as short and 15 min to an hour. Patients may experience mild redness and swelling. Most patients can resume their daily routine within 24 hours

Patience is required when treating wrinkled, rippled skin over the knees. It doesn't happen overnight. It takes about 3 months to see improvement and tightening continues gradually over time. 

We can now provide ThermiTight Injectable RF as an effective long-lasting option for skin tightening over the knees. Motivated, active women who strive to maintain a youthful face and tone muscles can now benefit with knees that match their face and the rest of their body.

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Erasing Sun Damage
October 13, 2015 11:11 AM by Mina Grasso
 Millions of people suffer from sun damage with excessive sun exposure. Brown spots are one of the most common reasons patients present to an aesthetic clinic. In addition, patients present with texture irregularities, concerns with precancerous lesions and skin cancer. In dermatology, actinic keratosis and superficial skin cancers are the most popular conditions treated with aminolevulinic acid (ALA).

Photodynamic therapy, (PDT), was originally approved by the FDA to treat actinic keratosis and early stages of the most common types of skin cancer (basal and squamous cell carcinoma). It is proving to successfully treat a variety of medical and cosmetic skin conditions like sun damage. Over the past years PDT treatments have become more refined and now provide a safe and effective, non-invasive treatment option for skin rejuvenation.

PDT is a simple office procedure where a chemical called aminolevulinic acid is applied to the skin to be treated. The ALA is applied to the skin after degreasing and exfoliation. It is usually left on the skin for 30 minutes to several hours after application depending on the severity and type of skin condition. 

The ALA is absorbed by rapidly growing damaged skin cells such as actinic keratosis (AK).  During the incubation time, there is no discomfort of heat or burning sensation. The ALA concentrates in the rapidly growing, sun damaged cells. After the incubation period, a laser or light source is used to activate the ALA. The damaged cells that have absorbed the ALA are destroyed by the light or laser energy. Several studies have shown dramatic and long-term improvement in inflammatory acne lesions due to absorption of the ALA in hair follicles and oil glands as well with PDT. 

A mild stinging or burning sensation may be experienced when the laser of light source activates the ALA. Moderate redness that feels like a mild to moderate sunburn can be expected for up to 7 days, depending on the case. 

With the advancements in the use of aminolevulenic acid, a photosensitizing agent combined with a laser or light source (ALA-PDT), cosmetic application results in improvement of long-term sun damage in patients. Large areas such as face, neck, chest, arms, and legs and back can be treated safely. All skin types can be treated with ALA-PDT. In addition to treating obvious areas of concern, cosmetic benefits have been observed in the surrounding skin. Patients can expect to experience improvement in the overall appearance of the skin including decreased redness, brown spots, known as sunspots of freckles, reduction in fine lines and improvement in skin texture. One application shows significant improvement, but two may be required for optimal results. 

ALA-PDT is an excellent option for those who accumulated excessive sun over the years and desire healthy - more youthful appearing skin. It is becoming a popular way to erase sun damage while erasing some superficial skin cancers.

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No Injections, No Incisions
September 29, 2015 11:37 AM by Mina Grasso
No matter how much you diet and exercise its difficult to get rid of submental fat which is known as "double chin", neck fat or "turkey neck." It is caused by excess fat deposits that accumulate under the chin and neck. Submental fat may be related to lifestyle, age or genetics. Unlike other body parts that can be concealed with clothing, double chins are difficult to hide. Double chin is a top concern for those seeking aesthetic procedures. The American Society for Dermatologic Surgery in 2014 found that 68% of people surveyed named excess fat under the chin and neck one of their top concerns. 

A double chin usually makes people look older. Some people don't realize they have a double chin until they see an unflattering photo. People usually notice their double chin in photos or when they look in the mirror. Caution is taken while posing and multiple adjustments are made to avoid the double chin which can kill a "selfie."

For years we have been successfully treating fat deposits on the abdomen, love handles, back, thighs and bra fat and under arms with Coolsculpt using the propriety science of cryolipolyisis technology. This procedure has been successful in over two million treatments throughout the US. 

Cryolipolysis works by exposure of fat cells to extreme cold. The fat cells die and are eliminated from the body permanently. Croyolipolysis selectively freezes the fat cells while bypassing the patient's skin. Twenty to twenty-five percent of fat cells treated are destroyed each treatment session. 

With Coolsculpt's introduction of a new uniquely designed applicator and the expanded clearance by the FDA, the CoolMini applicator, with the size, shape and curvature allows us to comfortably fit small problem areas. We are now able to treat smaller fat deposits such as the submental fat or double chin. This provides a non-invasive, non-surgical alternative to liposuction and is performed without injections or needles. There is little to no downtime. Most patients can resume regular activity immediately.  

Results may be seen as early as three weeks with the most dramatic results noticeable in one to three months after treatment. Optimal results are usually achieved in one to two treatments.

Patients can say goodbye to their "double chin", neck fat, "turkey neck or neck giggle." In with just one to two treatments, patients can experience a more attractive, better-defined youthful jawline. "Seflies" can then be taken comfortably and confidently in any position.

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Radiesse
September 15, 2015 8:44 AM by Mina Grasso
With the advancements in aesthetic procedures and products, faces are looking more youthful making it a challenge to guess someone's age. Faces are usually noticed first, so we spend much effort and money to rejuvenate and protect it, but hands are often ignored and premature aging of the hands can occur. Hard work, taking care of kids, your profession, hobbies and a bit of excessive sun exposure have all contributed to the weathering of those once-lovely hands. When aging hands are discovered, a different story is revealed. Aging hands do not match the youthfulness of the face.

Radiuses, is a dermal filler for the correction of volume loss for the face, has been available for many years. It was first approved in the United States in 2001, and has since had subsequent approvals, including for correction of nasolabial folds in 2006.  We have been using it off-label for hand rejuvenation. It has been approved in 52 countries for volumization of the dorsum of the hand since it has been available. Radiesse has proven to be a very versatile durable contouring product for the face in areas such as the chin and cheek where larger volumes have been required.  In June of this year, the FDA approved the use of this dermal filler to correct volume loss on the dorsum of the hand.

Aging hands are a complaint of many patients. Hands look older over time due to a combination of factors. Excess sun exposure reduction of collagen and elasticity in addition to volume loss makes veins and tendons appear more prominent. When volume is replaced in the dorsum of the hands, it minimizes the appearance of the veins and tendons. Radiesse hand rejuvenation, an innovative procedure, is not only for older women, young women especially with low body fat who are concerned about the appearance of their hands often requests this procedure. These women may include a bride- to- be with wedding ring photos, those working in the public with frequent hand exposure, models etc.

Radiesse is a dermal filler composed of synthetic calcium hyroxylapatite microspheres, which are suspended in a water-based gel carrier. In addition to being a dermal filler, Radiesse functions as a bio-activator. It provides a scaffolding for the newly produced collagen, which looks and feels soft, natural and smooth.  When a patient's own collagen forms, it tends to provide a longer lasting result.

Patients can experience immediate results after the Radiesse is injected and the volume is replenished in the back of the hands. In addition to the benefit of volume with Radiesse, patients will experience the unique benefit of bio-activation. Bio-activation stimulates collagen production and improves the quality of the skin that is treated. The soft, smooth and natural-looking appearance of hand rejuvenation with Radiesse is said to last about about a year. In some of our patients we have seen results up to two years. One syringe per hand is recommended. Radiesse is an innovative way to return long-lasting youthfulness to aging hands.

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Natural Beauty Utilizing Platelet Rich Plasma
September 1, 2015 11:46 AM by Mina Grasso
The number of ways to improve one's appearance is ever-increasing. The spectrum includes efficacious medical non-surgical procedures such as therapeutic skin care regimens, laser rejuvenation with non-ablative and ablative lasers and liquid facelifts incorporating a combination of neuromodulator and tissue fillers. Natural-appearing beauty is the desire of many. The other end of the medical spectrum involves surgical approaches such as facelifts, which although often flattering, can change a person's appearance.

The buzz, fascination and growing popularity with platelet rich plasma (PRP) is related to the ongoing search for natural beauty. Platelet rich plasma allows a patients' own regenerative capabilities to enhance their beauty. PRP has multiple applications for the aesthetic and the non-aesthetic world such as orthopedics and veterinary specialties. 

Bioactive Molecules found in α- Granules of Platelets

  • Growth factors
  • Adhesive proteins
  • Clotting factors
  • Fibrinolytic factors
  • Proteases and antiproteases
  • Basic proteins
  • Membrane glycoproteins

Platelet rich plasma is the processed clear plasma that is separated from the red blood cells from the patients' own blood. This platelet rich plasma is very rich in growth factors and is about 3-5 times more concentrated in these factors than unseparated blood.  It is has been associated with enhancement in healing.

Growth Factors That Have Been Identified in PRP

  • PD-EGF: platelet-derived epidermal growth factor
  • PDGF-A & B: platelet-derived growth factor
  • TGF-B1: transforming growth factor
  • IGF I, II: insulin-like growth factor
  • VEGF: vascular endothelial growth factor
  • ECGF: endothelial cell growth factor
  • bFGF: basic fibroblast growth factor
  • CTGF: connective tissue growth factor

These growth factors send an attraction signal to dormant unipotent stem cells in the skin, and then stimulate a repair response, enhancing the growth of new younger skin cells. This results in activation of the desirable skin rejuvenation process.

Platelet Rich Plasma in the aesthetic world has captured interest for skin rejuvenation from head to toe. It can be used on the scalp for hair restoration, on the face body for a more youthful glow or for scar reduction to reduce post inflammatory hyperpigmentation and improve skin texture irregularities. 

When we first introduced PRP in our clinic several years ago, we injected it with and without other tissue fillers, particularly, hyaluronic acids. When a patient requested it without tissue fillers, it meant injecting several spots throughout the face usually spaced 1cm apart. This resulted in severe down time due to bruising. When patients described the benefits they felt, they were willing to go through the process again, even if bruising occurred.

Fortunately, as the aesthetic world advanced and new procedures and techniques became available, combining PRP with these procedures made sense. One of our most popular procedures to use the PRP with is micro-needling. The other application that we have instituted is PRP after CO2 laser resurfacing. Micro-channels are made in the skin using the needling device or the factional laser. At the completion of the micro-needling or the fractional CO2, the plasma is placed directly on the area treated with micro-needling or fractional laser, which penetrated through the micro-channels. The plasma rich in growth factors then communicate with the stem cells and start the process of rejuvenation with the growth of new more youthful cells. This has provided us with a means to deliver the PRP without the prolonged bruising of multiple injections. Blunt cannulas used for tissue fillers can also be used to rejuvenate the skin to deliver the PRP into the skin with minimized risk of bruising.

Patients may appear to have mild sunburn immediately after the procedure. There may be pinpoint bleeding depending on the depth of treatment. This is usually not noticeable the following day. Partially due to the healing properties of PRP, there is minimal to no social downtime making this a very desirable option for patients. PRP can be used immediately after ThermiTight RF skin tightening (Injectable RF) procedure for the jowl and neck and other body parts to further enhancing the benefits of rapid healing and improved rejuvenation of a patient's own natural beauty. Adjuvant treatment with platelet-rich plasma is yet another advancement in the quest for efficacious skin treatment.
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Restoring Feminine Youthfulness
August 18, 2015 10:31 AM by Mina Grasso
Aesthetic concerns of women go beyond the face and common body treatments.   Over the last decade the term "Mommy Makeover" has increased in popularity.  Going beyond that women have sought solutions to restore feminine youthfulness.   Many don't bother reporting issues because they have accepted it as part of the aging process. Others due to cultural reasons are horrified to consider discussion or deny they have any issues. When bringing up the topic usually with their GYN practitioner, overactive bladder and stress incontinence are usually more acceptable topics to start the discussion. This may lead to discussion of vaginal laxity or looseness and other vulvovaginal issues like atrophy, lack of lubrication and dryness especially in the perimenopausal and menopausal ages. Orgasmic disorders and sexual desire are issues rarely brought up by patients largely due to acceptance with aging and hormonal decline.

ThermiVA is a revolutionary solution to restore feminine youthfulness for our patients who desire cosmetic enhancement of the vulva and have experienced the additional benefits of resolving their incontinence and have reported improved orgasms. 

ThermiVA is a non-invasive procedure that requires absolutely no downtime. It utilizes a controlled radiofrequency platform. A small applicator with a temperature sensor at the tip is used to heat the tissue of the vulva and the vaginal canal. It uses temperature as a clinical endpoint to smooth skin and shrink mucosa. Heating the skin and mucosa promotes immediate contraction of collagen, immediate collagen remodeling and elasticity, and long term stimulation in producing new collagen. It is believed that incontinence and sexual function is improved by tightening of the pelvic floor, and the thermal input may stimulate chemotaxis and release of growth factors resulting in angiogenesis and neurogenesis.

ThermiVA is the current WOW of the practice. Patients describe the procedure with the sensation of a hot stone massage on the vulva and report a pressure sensation with virtually no pain in the vaginal canal. No pain medication or anesthetic is required. With more patients demanding non-surgical options that provide long-lasting results without downtime, patient satisfaction is extremely high.

Patient testimonials:

"I am a 65 yr old woman that had experienced a decrease in sensation during sexual activity. My orgasms were lackluster if they even occurred. I heard of the ThermiVa procedure and had my first treatment 7 weeks ago. It was a short and comfortable procedure in a most aesthetic environment. There is no down time with this procedure so was anxious to see results. All I can say is "WOW."  All of my vaginal nerve cells came alive. It was like having intercourse 20 years ago. A few weeks ago, I had the second procedure with this treatment. I noticed tightening of both the external labia and vulva. The sensation is phenomenal and I am truly satisfied."

"Walking, laughing, sneezing, coughing frequently caught me in the embarrassing situation of uncontrollable dribbling. After the 1st of 3 ThermiVa treatments the improvement was surprising. I didn't expect results to occur within hours of the procedure, but they were. I'm able to "clench" and stop mid-stream (just as a test). The month after the 1st treatment has been a relief from worry because I know I can control and prevent leakage."

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Cellulite Treatment with Thermitight
August 4, 2015 3:20 PM by Mina Grasso
Even among the healthiest women 75-85% suffer from the unsightly appearance of cellulite. It can even be seen in young teens and even infants. The cause of cellulite is not fully understood. It is virtually non-existent in men due to the thickness and structure of skin as influenced by male sex hormones. Some common theories include the following: poor circulation, herniated fat cells, water retention, fibrosis of connective tissue and accumulation of toxins in the fat tissue that may be a result of lack of physical activity or hormonal imbalances. Cellulite is defined as persistent subcutaneous fat causing dimpling of the skin, especially on women's hips and thighs. Some have classified different types, as in the appearance of surface skin depressions when a woman crosses her legs, versus a constantly present orange peel deformity.

The search for effective treatment of cellulite has been a source of frustration for women for years. Over the years claims have been made for various treatments including creams, brushes, dehydrating wraps, cellulite garments, magic pills and fitness contraptions. Our involvement with cellulite treatments started almost 20 years ago using Endermologie, which is still an effective short-term treatment using a system of vacuum and rollers. As laser aesthetics developed, awareness in treatment of cellulite grew and patients would demand the latest technology that they saw on TV. We found ourselves replacing previous cellulite technology with the latest, more advanced to attempt to provide the best solution for our patients. We have had as many as four devices at one time. 

The results of cellulite treatment with our prior technologies are short-term and patients require multiple treatments on average one to two treatments a week for 6-12 weeks. Motivated patients accept this just to get mild improvement of the unsightly dimpling. We have a few patients who come routinely, seasonally, while a few come for treatment year round.  

ThermiTight, a skin-tightening procedure that was developed to tighten skin on the face, neck, arms, abdomen and other parts of the body works by stimulating collagen production with radiofrequency energy. Radiofrequency energy is highly penetrating and can be delivered beneath the skin to stimulate collagen production-which can result in the tightening of skin and improve the appearance of cellulite. ThermiTight is a great option because it can improve tightness, smoothness, and produce more youthful-looking skin for all skin types. 

Cellulite treatment with ThermiTight uses a thin electrode about the size of a piece of spaghetti to deliver carefully controlled radiofrequency energy and temperature to the subdermal tissue where cellulite occurs. It is performed using tumescent diluted local anesthetic to maintain patient comfort throughout the procedure. The procedure is minimally invasive and requires minimal downtime. A desired level of energy is delivered gently and evenly with continual monitoring of the energy delivered with control to reach a target temperature with safety and efficacy. Cellulite improvement with skin tightening is gradual and can be long-lasting. Results can be seen starting in a few weeks, but continue to improve up to one year. 

Setting realistic expectations as in any aesthetic procedure is crucial and no guarantees can be made. Traditionally expectations have been set low for cellulite treatments and results are described as temporary. Genetics, hormone status, dietary and other factors may influence the patient's results. Some areas will improve better than others. Therefore it is quite noteworthy that some doctors using Thermitight treatment of cellulite started about three years ago and some patients have maintained results so far. We may finally have a longer lasting answer to cellulite improvement.

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Advanced Eyebrow Tattooing
July 21, 2015 9:47 AM by Mina Grasso
The new buzz in advanced permanent eyebrows is modern microblading micropigmentation also known as 3D Eyebrows, Eyebrow Embroidery or Feathering. Microblading is one of the oldest techniques used for cosmetic tattooing. In the last few years advanced modern tools have been developed making this technique a very sought after procedure that promotes a natural appearance.    A small pencil-shaped hand instrument with disposable microblades comprised of microneedles is used. The microblading technique it a much more refined technique using much finer needles than tradition micropigmentation needles that have been used for decades. The quantity of needles and the blade types can vary. 

The microblading micropigmentation hand instrument is used to delicately apply pigment as fine hair strokes with more definition and dimension resulting in the most natural-looking realistic soft eyebrows that can enhance a patient's natural features. Many patients are still afraid of getting their eyebrows tattooed largely as a result of people they know who have had cosmetic tattooing especially of the eyebrows that either had poor color selection but most often size, shape and the solid look of the tattooed eyebrows have dominated their faces. 

As with tradition cosmetic micropigmentation, the eyebrow color will appear much darker the first week. After the scab formation peels, the resulting color is closer to the end resulting color. This technique should enhance color retention longer than tradition methods. The color should last about 1-2 years.

Microblading is becoming a very popular technique for cosmetic micropigmentation of eyebrows in various parts of the world including Asia, Europe and the US.  Patients are seeking information on this exciting new technique from their hair stylists, cosmetic consultants and plastic surgeons. They are all seeking a natural soft appearance of eyebrows that can enhance their natural beauty that modern microblading can offer.

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    Occupation: Physician Assistant/Nurse Practitioner
    Setting: Miami & Upland, Calif.
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