What sets Xeomin apart from its competition is that it contains no binding proteins, giving it the nickname "naked" neurotoxin. In this "naked" neurotoxin complex, the therapeutic or active component is isolated and the surrounding ancillary proteins are removed. This formulation yields high biologic activity and low protein load which could mean less risk of the body developing antibodies against the product.

Such proteins may also have the potential to limit the neurotoxin's effectiveness and potentially make patients resistant to neurotoxins. Also in question is if removing the ancillary proteins affects the diffusion factor of the product. Some physicians have concerns about the spreading of Xeomin within tissue as it contains no proteins to protect the stability around the active molecule. 

Although the units between Botox and Xeomin appear identical, they are not bioequivalent and therefore units of each are not interchangeable. This will likely further be determined as it is used by more providers and a certain comfort level with the product and efficacious dosing is established. Xeomin does not require refrigeration prior to reconstitution unlike all other botulinum toxins currently on the market. This could lend to easier distribution as well as ensuring proper maintenance of temperature and thus efficacy of the product.

What does this new addition mean for the world of aesthetics? By having more options to choose from, competition among manufacturers will increase and likely bring costs down. I don't hear patients or providers complaining! 

Among Xeomin are other botulinum toxin products which are either under clinical investigation or currently seeking FDA approval. Such agents to look out for include:  Reloxin (a purified version of Dysport, manufactured by Medicis) and Purtox (manufactured by Mentor). With limited cosmetic data and provider experience with Xeomin, much remains to be seen how it will fare in the aesthetics market. One thing is certain, as the most popular cosmetic procedure in the world, we are sure to hear a lot more about Xeomin and these other botolinums in the near future.

It is the most popular non-ablative skin rejuvenation treatment that has continued to show clinical improvement of skin quality with little to no downtime, hence the name "Fotofacial."

With a series of treatments, patients can experience the following:

• Healthier, smoother skin
• Reduced redness and flushing
• Reduced pore size
• Reduced fine lines and wrinkles
• Reduced sun damage
• A more youthful look
• More even skin tone
• Increased self-confidence
• Increased collagen bundles

Recently a pilot study conducted by Anne Lynn S. Chang M.D. et al.  showed evidence of rejuvenation at the genetic level. "Rejuvenation of Gene Expression Pattern of Aged Human Skin by Broadband Light Treatment" is published in the Journal of Investigative Dermatology (2013) 133, 394-402; doi:10.1038/jid.2012.287; published online 30 August 2012.

Study participants were treated with a series of 3 treatments on the forearm of broadband light (BBL), 4 weeks apart. Skin biopsies used to obtain genetic material were taken from the participant's treated area and a variety of comparisons were made to the adjacent non-treated area. 

The researchers used gene-sequencing technology to examine the effects of BBL on skin aging. BBL is also known as IPL - Intense Pulse Light or photo rejuvenation. They found that skin aging was associated with a significantly altered gene expression level, which became "rejuvenated" after a series of BBL treatments. The skin biopsies taken from the areas treated with BBL showed gene expression level more similar to youthful skin. 

This gives us a better understanding of what happens on the molecular level of skin rejuvenation using broadband light  (BBL, IPL). A series of photorejuvenation treatments can restore the gene expression pattern of skin aged due to intrinsic genetics or environmental factors and will then resemble younger skin.

Gene sequencing is new technology that will continue to help researchers learn more about the aging process of human skin and can now be used to show the miracle transformation of skin using Intense Pulsed Light - hotorejuvention.

Vivatia is an advanced skin care system offering patients undeniable results. This system is a new take on anti-aging skin care, focusing on safe and effective delivery of key ingredients such as anti-oxidants and hydroquinone.

Vivatia consists of 3 steps:

Gentle Cream Cleanser - A non-foaming cream cleanser that is hydrating while it cleanses to remove impurities. It is specially designed for use with high-potency retinoid therapy that we all know causes cell turnover (peeling) and in patients' eyes "dryness." To calm the skin this cleanser contains green tea, aloe vera and chamomile.

Active Repair Complex - A unique retinol formula with peptides, vitamins and antioxidants which help to reduce the appearance of fine lines and wrinkles for more radiant, younger-looking skin. This product is available in 0.5%, 0.75%, 1.0% pure retinol concentrations. It is recommended that patients start at 0.5% and work up. 

Brightening Coplex - This formulation combines 10 powerful brightening agents to help even skin tone and fade dark spots. Included in this complex is 2% hydroquinone, as well as niacinamide, whitonyl (palmaria palamata extract), kojic acid, licorice root and arbutin. 

How is Vivatia different from other anti-aging products? Well for starters, Vivatia utilizes the proprietary foam delivery of retinol - making the product "tough on aging" yet "gentle on skin." Unlike some harsh products that make patients red and have unwanted peeling, this system does the job with little irritation. 

I love this because patients will really see results with minimal redness or peeling that interferes with their busy life style. We also love that with proper sun protection, this product is safe for those who enjoy outdoor activities. Also, this product contains a formulation of low dose hydroquinone (2%) that is safe to use year round. 

It's difficult to predict how patients will respond to these various treatments. Most see improvement, but results cannot be guaranteed. Usually, a series of treatments are required. The following technologies have been successful in our practice.

Acne Light (Omnilux Blue and Red Light)

• Blue light is the most commonly used. It targets P. acnes.
• Red light can be added in the regimen to help reduce the inflammation of acne.

Combining the two has been very effective for most patients. There is no downtime using either light alone. One 20-minute session of each light per week for 4-8 weeks is recommended.

Photodynamic Therapy (PDT)

A photosensitizing drug such as ALA - aminolevulenic acid is applied to the skin and left to incubate for period of 30-60 min. (incubation period may vary in other practices). During this incubation period, ALA is absorbed by rapidly growing cells such as precancerous cells and other cancer cells and has recently expanded with great success in the treatment of acne.

After the incubation period, the skin is exposed to a light or laser source that activates the chemical absorbed to destroy P. acnes and will reduce the size and activity of the sebaceous glands. Patients must be advised to avoid sun exposure for 3 days. They will experience redness and exfoliation for 3-5 days but will result in faster resolution of acne.

Coolbreeze/CoolTouch Laser - 1320 nm

PhotoRejuvention - Intense Pulsed Light (IPL)

Spectra Acne Laser Toning - Q-switched Nd:YAG 1064

V-Beam Pulsed Dye Laser - 595nm

Thermage Monopolar Radiofrequency

Patients will experience reduction of non-inflammatory and inflammatory acne lesions using one or a combination of the laser and light technologies above combined with their topical acne regimen. These laser and light treatments have unique qualities depending on the wavelength and parameters used, but have overlapping benefits.

Most patients notice a marked improvement in their general skin condition due to collagen stimulation. They can experience pore size and sebum reduction as well as reduction of redness and post-inflammatory hyperpigmentation (PIH) from acne inflammation.  Using a series of one or a combination of these laser and light technologies have improved our management of acne and acne scarring without causing any surface damage.

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The best care for scars starts immediately. Knowing the proper care and treatment for potential scarring is important to know before the damage is done. Among my favorite initial scar treatments is the topical use of Biocorneum. This silicone based gel acts as an anti-inflammatory, improves redness of scars and helps to diminish their size and overall noticeability. 

For best results it should be applied twice a day and massaged into the scar tissue softly. Biocorneum is available at physician offices only, where it is dispensed. Over the counter alternatives, which can be found in stores or online, include products such as Mederma, Kelocote and Scar Guard.    

While Biocorneum does contain sun protection, I always recommend a physical sun block be used concurrently. The sun loves to further accentuate vessels and redness, which we want to decrease in scars, so protection from the sun is essential.

Scars reach their maturity by about one year. The first few months are by far the most important. As scars approach 6 months and on there is less of a chance for improvement. If hyperpigmentation exists you may need to add a bleaching agent to lighten. Every case is always unique -- one of the true beauties of aesthetics. 

After you've done everything you can with creams, the best in-office treatments include fractionated lasers (for textural discrepancies) or lasers which target the redness (for vascular changes). My approach after good topical care is typically with a combination of fractionated laser treatments and IPL (Intense Pulse Light) sessions. I always stress to patients that no treatment removes a scar. If you make that clear prior to treatment their expectations are much more realistic and both parties are happier. And as always, start treatment as soon as possible for best results! 

Acne can range from mild blackheads and whiteheads (comedonal acne) caused by pores blocked by sebum and skin cells to inflammatory acne that usually presents with redness and inflammation under blocked pores. The most severe form of acne is cystic acne. Cystic acne usually is painful related to a deeper bacterial infection most commonly by propionibacterium acnes. Cystic acne may lead to disfigurement and result in residual scarring and the goal would be to treat as soon as possible to avoid further scarring.

Over the Counter Remedies

For milder cases of acne, various soaps, washes, toners and cleansers have been effective. Two of the most common are benzoyl peroxide and salicylic acid. Benzoyl peroxide acts as an antibacterial treating propionibacterium acnes. Salicylic acid is a keraolytic agent that softens and exfoliates the outer layer of skin, the stratum corneum, and helps prevent clogging of the pores with sebum and skin.

Prescription Acne Skin Care

• Azelaic Acid solution can be useful in treating mild comedonal acne. Patients usually do not complain of irritation with use of this product.
• Topical Antibiotics such as clindamycin, erythromycin and sodium sulfacetamide have been effective against propionibacterium acnes.
• Topical Retinoids work to reduce outbreaks by modulating cell turnover, which prevents inflamed skin cells from clogging pores. It reduces the frequency and severity of acne breakouts. Side effects such as increased sensitivity to sunlight, dryness, redness and peeling need to be discussed. These side effects can be managed to improve compliance with treatment.

Combination Topical Therapy

Antibiotic resistance is always of concern. Combining topical antibiotics with benzoyl peroxide has been one approach to reduce antibiotic resistance. In addition, combination therapy using clindamycin or erythromycin with low dose benzoyl peroxide has proven to be more effective than clindamycin or erythromycin alone, in some studies.

Combining topical retinoids enhance the penetration of topical antibiotics and improves treatment outcome. Later this month, I will address added benefits to combination therapy using laser and light technologies.

Tired of buying over the counter products that just don't work? So are patients! One of my passions for what I do is finding just the fix for someone -- something that will work and improve their condition. Pharmacy aisles and mall cosmetic counters are now flooded with an overwhelming quantity of products of varying efficacy. 

Let's be honest -- some of these products just don't do what they claim. These products do not pass through the FDA's approval process and do not have a high standard of regulation. Cosmeceuticals, with their indication for use regulated by medical providers, really are in my opinion a great option and an answer for patients.

Why offer cosmeceuticals in your medical practice? They are an essential tool for dermatologists and cosmetic specialists. We are results-driven and patients are also driven by results. Most patients like the convenience of in-house recommendations rather than attempting to find products online or over the counter. 

In my personal experience, if a patient leaves with a product, versus the name of one or handed a prescription, they are much more likely to use the product and therefore improve their condition. Now this doesn't mean you need to sell every product imaginable. Have products that you stand by and have proven with experience to work. Write a prescription when it is the better product for a patient. But don't be afraid to have it there for them!    

Many cosmeceuticals are now available online or even on an over the counter basis. How can you set your products apart? With branded products. Branding your own products has been increasing in popularity as more and more cosmeceuticals are available outside of medical offices. Many companies offer the option to brand their products with your company name and logo to dispense. A win-win in my book.    

Brown spots may include:

• birthmarks
• freckles
• brown patches
• moles
• hyperpigmentation (due to inflammation or trauma to the skin from acne)
• insect bites
• abrasions

The most common cause of brown spots or age spots on the face, chest, arms and hands is sun exposure. Melanocytes produce melanin to protect the skin from the sun's ultraviolet light; however, sun exposure can cause an excess production of melanin, leading to unwanted brown spots.

Patients frequently present in our clinic with complaints of unwanted brown spots or marks on their skin. After carefully taking a patient's history, evaluating the skin, and ruling out the need to refer to a dermatologist for suspicious lesions, a variety of brown spot treatment options can be offered. First, the most important step is prevention with broad-spectrum sunscreens.

Treatment Options

Topical bleaching agents such as hydroquinone and kojic acid, alpha hydroxyl acids and tretinoin may be helpful individually or in combination in reducing the pigment and may help in reducing the incidence of PIH (Post-Inflammatory Hyperpigmentation) as a result of treatment for the brown spots, especially in those with darker skin types. 

A range of laser and light-based technology has rapidly improved the efficacy and safety of treatment for brown spots. Laser or light based procedures that can be performed provide little to no downtime; however, several treatments may be required.

Photo-rejuvenation, also known as FotoFacial or IPL (Intense Pulse Light), is a light-based treatment used to break up melanin by reducing surface pigment gradually. Most devices now have contact cooling which makes the procedure much safer for most skin types. Laser toning using a Q-switch laser 1064 nm can break up pigment gradually, be used on all skin types and can be accomplished without giving the patient any down-time. 

The 532 nm wavelength for treating brown or age spots provides more rapid results, but requires social downtime. The laser emits the energy that is absorbed by the melanin and vaporizes the brown spot. During the procedure the lesion turns from brown to a grayish color, which develops into a small scab within a few days. After the scab comes off, the skin is pink initially and usually regains pigmentation blending with the surrounding skin. 

Healing time varies with the location of the body being treated and energy level used. On the face I have my patients expect 5-6 days of healing. The neck and chest may take 7-12 days while extremities may take 2-3 weeks. Great caution is needed when treating skin-types on the Fitzpatrick scale of 4 or greater.

There has been controversy with prepping the skin with bleaching agents and tretinoin pre- and/or post-treatment. I personally encourage pre- and post-treatment in conjunction with use of a broad-spectrum sunscreen daily post treatment. 

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If your "anti-aging" eyes wander like mine, you are probably interested in more than just facial rejuvenation. Below the face and neck we have several very important areas to consider. Take for example the décolletage.

One concern many patients have is aging of this region- think wrinkles, sun spots and loss of collagen and elastin within the skin. With the use of medical grade creams, such as retinol and growth factors, the skin integrity can be greatly improved. However, these creams do not address the generalized laxity and crepe-like quality we can see develop in the décolletage as we age.

One interesting topic I came across more recently is the use of décolletage "pads." If you were like me when I first heard of the approach, you are thinking: What did she just say? But really, these pads do exist, and in fact are a very real and popular treatment modality for rejuvenation of the chest. Such pads are reusable and washable (often self-adhesive) that are designed to correct and prevent chest wrinkles caused by aging and the sun as well as sleeping on your side and stomach.  

One of the more common requests patients come to our clinic for is treatment of brown spots. As the world of aesthetic laser practices grow, and more people are aware of laser treatments for skin rejuvenation, the demand for brown spot removal increases.

Unfortunately, in some aesthetic practices, consultants without dermatological training are the ones who are recommending various treatment modalities to patients presenting with brown spots. 

Anyone involved in a skin examination should be familiar with the ABCDs of melanoma detection and know when to refer to a dermatologist.

Border Irregularity - Is the edge (border) of the mole ragged, notched or blurred?

Color - Does the mole have a variety of hues and colors within the same lesion? 

Diameter - What is the size of the mole? While melanomas are usually greater than 6 millimeters (about the size of a pencil eraser) in diameter when diagnosed, they can be smaller. 

Patients with increased risk of melanoma include:

1. Family history of melanoma
2. Atypical moles greater than 6mm
3. Fair skin types that usually burn
4. Have more than 50 moles
5. Diagnosed with actinic keratosis
6. Long history of sun exposure
7. Weakened immune systems caused by disease or immunosuppressive medications
   

Although I have had some experience with medical dermatology and performed skin biopsies, if a patient presents with a brown spot that appears suspicious and different than other surrounding spots or if he/she reports changes, pruritis or bleeding, even if it is less than 6mm in diameter, I prefer to refer any suspicious lesion to a dermatologist. 

Know your ABCDs of melanoma detection and educate patients on sun protection for prevention of premature aging of the skin and skin cancer.

Trends in aesthetics are evolving to provide patients with less invasive treatment options. The under-eye region remains a common area of concern for patients. With age, skin responds more slowly to pulling and its recoil time lengthens as the integrity of collagen and elastin is compromised. 

Research involving the skin integrity in the under-eye region proved there was something to be done about that and it could be done non-invasively. Thus, there is a new treatment modality in pre-trial for patients concerned about the all so common darkness, puffiness and under-eye bags.

The treatment (unnamed until it has FDA clearance) is a completely non-invasive treatment for lower lid rejuvenation. It is a biomaterial which was created by dermatologists and biomedical scientists to smooth, tighten and hydrate lax, aging skin. The material is applied topically with results becoming visible soon after application (in as little as one hour). 

The system works with a two step application process. First, the contouring complex is applied, which contains the propriety biomaterial. Then the activator is used to activate the complex to form an invisible, breathable material that tightens lax skin. The results last throughout the day with noticeable improvement in puffiness, reduction in bags and fine lines and wrinkles. Best of all, this is all achieved without surgery.

Benefits of CO2 Fractional Laser Resurfacing Treatments

The skin then heals over a period of time, as new layers of collagen are produced. The treatment results in an improvement in the appearance of sun damaged or acne scarred skin. In addition, the post treatment skin will have a healthy look along with a better texture and tone. 

This intensive treatment can significantly reduce the appearance of lines, wrinkles, and pigment changes on the face, neck and other parts of the body. The laser can be used to treat delicate areas such as lines around the lips, eyes and even eyelids or over the whole of the face. Acne and other types of scars and certain stretch marks can also be improved.

Winter is an ideal time for patients to have laser-resurfacing procedures performed with less risk of sun exposure following the procedure. With vacation from work or school schedules, patients can afford more downtime during the holidays. 

Potential CO2 Laser Resurfacing Side Effects and Complications

Although CO2 fractional resurfacing is a safer alternative to traditional CO2 resurfacing, it is not without complications. We expect all our patients to experience some redness and swelling. Depending on the parameters used and location treated, redness can last 3-21 days. There have been reported cases of redness lasting up to 3 months. Acne or milia and hyperpigmentation are the most common side effects we deal with in our clinic. We have been favoring the fractional CO2 laser over our non-ablative Fraxel Restore laser due to lower incidents of the acne, milia and hyperpigmentiation. 

Hyperpigmentation may occur with post laser sun exposure and more frequently with darker skin types. Despite careful sun precautions some patients still develop hyperpigmentation. At the opposite end of the spectrum, hypopigmentation may occur.  It's rare, but usually permanent. Hypertrophic scarring and ectropian, also rare, may occur. 

Aftercare Instructions

Patients must be given verbal and written aftercare instructions following their laser treatment. Giving instructions to them a week prior to treatment is ideal so they can prepare to have appropriate aftercare products available. Contact dermatitis can occur when they attempt to use their usual skin regimen or use OTC skin remedies when their skin is still in the healing process post laser resurfacing treatment.

Among the most important concepts to master prior to performing neuromodulator injections is to fully understand muscle anatomy in the region. Below are among the most commonly injected muscles on the head and neck for cosmetic purposes:

Frontalis: This is the muscle responsible for the horizontal forehead lines. When this muscle is injected with a neuromodulator it softens the elevation of the forehead and brows. Too powerful of injections, especially laterally in the forehead just above the brow, can cause drooping. So caution must be taken to avoid over correction.

Corrugators: These muscles work together to form the infamous "11s" or vertical lines in the glabella. Together with the procerus muscle (see below), the corrugators contribute to the hyper-functional movement between the brows forming vertical lines.

Depressor Supercilli: These muscles also play a key role in forming vertical lines in the frown or glabella area.

Orbicularis Oculi: These muscles are responsible for closing the eye and allow for squinting. This muscle forms crows feet, or the thin horizontal lines around the eyes.

Procerus: Alongside the corrugators, this muscle lies within the center of the glabella and is also a contributor to frowning, resulting in horizontal lines in the glabella.

Platysma: This is the large muscle of the neck which as we age may form very visible bands and sagging. Injection into this muscle results in a smooth and lifted neckline.

Nasalis: This muscle is responsible for forming "bunny lines" or horizontal lines in the glabella and along the sides of the nose.

Orbicularis Oris: This is the muscle around the mouth that may lead to vertical lines or "lipstick" lines with chronic use or pursing of the lips. Older patients may complain that they cannot apply lipstick without it running. Lines caused by this muscle are typically more evident in individuals who are/were chronic smokers.

Depressor Anguli Oris: Originating at the inferior border of the mandible at the vertical level of the midpupillary line, this muscle inserts onto the corner of the mouth, forming lines that may begin to angle the mouth downward. To subtly elevate the mouth the DAOs may be injected.

It is important to note that lines form perpendicular to the way the fibers of the muscle run. So as you review your anatomy book this makes it much more clear where and how the lines are formed over time. Remember, understanding facial anatomy is essential, but just as crucial is recognizing the unique anatomy in each individual. Some patients have very prominent muscles while others may not require as much in certain areas to soften. No two patients' features or musculature are identical, so certainly understand facial anatomy, but treat each patient unique to their needs.

The skin around the eyes is one of the first places that reveal a person's age. The delicate skin under the eyes that contains less subcutaneous fat becomes thinner with age. The unsightly age-related changes include dark circles, "bags" or swelling and puffiness, crepy skin under the eyes and "crows' feet." Patients often complain that they frequently get comments that they "look tired."

Every year, millions of dollars are used to conceal dark circles and wrinkles around the eyes.  Patients can be educated in key ingredients that have been studied to remedy some of the physiological conditions that create the appearance of dark circles and wrinkles while improving aging skin.

Heredity is a component in the rate of aging around the eyes, but external factors that trigger inflammatory processes such as sun exposure and smoking or irritants can increase production of enzymes that break down cross-linked collagen fibers in the skin that compromise the flexibility, strength and thickness of the skin. Dark circles and puffiness may be caused by poor hemodynamic properties with fine capillaries or reddish-blue blood vessels that appear more visible under the compromised thin translucent skin.

The appearance of dark circles can be reduced using Dark Circle Eye Cream, which contains a combination of vitamin K, arnica, a complex of soy and rice peptides, yeast protein and hyaluronic acid.  These products work synergistically to reduce dark eye circles and puffiness while restoring a youthful tightness to the eye area. 

Patients who still have great fear in the use of neurotoxins like Botox and Dysport or who want to enhance and prolong their results after injection of these neuro-toxins can benefit from nature and neuro-chemistry combining neuro-peptides and active botanicals united to combat wrinkles.

Reduction of crows' feet, frown lines and other dynamic wrinkles has been shown to occur using a fusion of neuro-peptides and active botanicals found in Super Peptide Eye Serum which contains high concentrations of these scientifically proven peptides to boost and extend Botox and Dysport results.

This complex of peptides and botanicals found in Super Peptide Eye Serum has been shown to reduce wrinkle depth 50%+ while increasing skin tone (firmer, lifted skin). It has proven to stimulate cellular turnover creating a more youthful, refreshed appearance.   

I recently attended an aesthetics conference in south Florida. There were many great speakers- seasoned cosmetic surgeons and dermatologists, successful CEOs, and highly-acclaimed skin care specialists. Aside from learning about new and improved aesthetic technologies and techniques, a specific speaker enlightened me before he even began his lecture. 

This particular physician spoke on his experiences with various cosmetic treatments, but he began his lecture with a simple message: Remember compassion throughout your career in aesthetics. He shared a few stories of examples he had experienced in his own career and spoke with such enthusiasm and emotion behind his words. You could tell this man truly loves what he does and has a special effect on people.

This hit home for me because in this room filled of highly educated, although some overly-injected individuals, I think we must never stop practicing compassion. In a busy world and work day this can easily get overlooked. We must never become so busy or so concerned with aesthetics that we forget that compassion plays a large role. In a day spent nipping and tucking, or simply encouraging at the office, remember that people elect to undergo cosmetic procedures to look better so that they feel better. The benefit of some procedures on an individual's self-esteem can be life changing. Remember that the patient in front of you is more than a treatment and it is about much more than making that person look better. It is about the feeling you give them and the confidence they gain in the process.

Aesthetics could certainly be simply superficial if you make it just that. However, I am a firm believer that beauty is more than skin deep. If we practice with compassion, the whole world slows down for a moment and we make great results even better. We make people feel not only beautiful but most importantly happy, satisfied, ready to conquer the world. If a patient no longer looks at a slight imperfection, or even a more obvious one, and pushes their thoughts towards what they do have going for them, we have succeeded in aesthetics.