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Aesthetics Practice Today

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.

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.

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.

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.

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.
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."

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.

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.

Stretch Mark Therapies
July 7, 2015 12:29 PM by Mina Grasso

Stretch marks can be found on various parts of the body including the abdomen, thighs, hips, breasts, and arms, behind the knees, flanks and low back. Both men and women at different ages can develop these stretch marks.

Stretch marks can present differently depending on the skin type. They can range in color from white, silvery, pink, red, reddish purple to dark brown. Stretch marks usually appear more pink and red in the early stages and as time goes by, they become more white or silvery and appear indented.

It was felt that rapid stretch of the skin alone was the cause of stretch marks. It is now believed that an increase in cortisone, a hormone produced by the adrenal glands, contributes to the development of these unsightly parallel linear patterns. Elastic fibers in the skin may be weakened by cortisone. Genetic factors may also play a role. The physical stretching of the skin and hormonal factors play a role in the development of stretch-marks in pregnant women, teenagers during a growth spurt, body builders with substantial weight gain, use of corticosteroid creams or systemic steroids as well as those with various disease processes that affect the adrenal glands.

Over the years people have spent hundreds of dollars on useless lotions and potions that claim to make stretch marks disappear. Limited data is available for topical solutions that improve stretch marks. Tretinoin (Retin-A) has been shown to improve the appearance of stretch marks when used in the early stages. It works by stimulating collagen production. However, skin can become very irritated and patients need careful guidance on proper use of this product. Unfortunately it cannot be used during pregnancy.

Although nothing has proven to eliminate stretch marks, there are various lasers and light energy that can improve the appearance. Early treatment yields better results. Intense pulsed light (IPL) and V-Beam, a pulse dye laser can reduce the red appearance of the stretch marks. Fractional laser resurfacing vaporizes away a fraction of the scarred tissue and is replaced with new growth of collagen and elastin resulting in renewed skin with improved texture and color.

A device called Viora Reaction, utilizing bipolar radiofrequency, has surprised us unexpectedly in improving the appearance of stretch marks. In our clinic, we use this device for cellulite and skin tightening, and have seen improvement in stretch marks in the areas that we have treated. So far we have not had patients report hypo or hyperpigmentation. Response to treatment will vary among individuals. 

Microneedling using the Dermapen has been a procedure that has yielded results beyond expectations. Different for the more traumatic dermal rolling, Dermapen utilizes groups of fine needles with adjustable depth of penetration depending on the condition to be treated. Collagen and elastin is stimulated by the microneedling to improve the appearance and texture of the skin. In addition, platelet rich plasma (PRP) can be applied topically immediately after the micro-channels are created, enhancing penetration of the PRP. This turns on the body's own regenerative process to repair the tissue being treated.

Realistic expectations need to be set. Results may vary depending on the severity of the stretch marks and the number of treatments. In many cases, a combination of modalities can yield the best results. These treatment modalities are costly and multiple treatments are usually required over a period of time. I tell all patients that stretch mark treatment is never 100%. Although these modalities can improve the appearance of the stretch marks, residual evidence of stretch marks may remain.

Restylane Silk: Smooth and Natural Enhancement
June 23, 2015 2:08 PM by Mina Grasso
The "liquid facelift" has been an innovative answer to the demand for a rapid non-surgical way to enhance and rejuvenate the youthful volume that has diminished with aging. Over the last decade this has been accomplished with various fillers, neuromodulators like Botox and biostimulators that encourage growth of one's own skin components.

The "liquid facelift" has allowed us to understand and teach our patients about the natural aging changes of the face that relates to volume loss from diminished fat, muscle and unfortunately even bone as well as thinner skin. As a result of an increased understanding of facial aging, we have changed the manner in which we approach facial rejuvenation with volume. New products such as Voluma have entered the market to help us approach our patients differently in order to restore a more natural youthful appearance. Often diminished deep fat pads can be supplemented to approximate an appearance one had in the picture we carry of ourselves in our mind. We have come a long way since the days of superficially placed bovine collagen that lasted around three months to products that can last up to two years. We have moved away from chasing lines to global volume replacement from forehead to chin.

Although tissue fillers have been around over decades, many patients are still hesitant and fear looking unnatural and overdone. Over the years they have witnessed others who appeared "ducky", "monkey-like," "puffy" or "too full."

One of the biggest "giveaways" that many have witnessed is a mature woman with vertical lip lines that have been over filled with Juvederm or Restylane and distorted the shape of the upper lip in particular creating a "Marge Simpson" look with the upper lip protruding much past the lower lip. Patient's facial structures and ideal shapes are very different. The goal is to understand the volume change for each individual that is enhancing and flattering and often will not be detected by an observer as "having some work done."

Restylane Silk is now available to address the challenges that we have had with other fillers. Patients are sometimes not interested in getting fuller lips but simply want to address the vertical lip lines. In certain instances this will be all that needs to be done. In addition, patients who have lost definition of the lips due to the natural process of aging, environmental factors and habits can benefit with subtle enhancement-like lip definition. I often recommend patients a more "hydrated" appearance of their lips with Restylane Silk as the product, hyaluronic acid, will indeed hold more water in the area like a younger person does with the higher natural hyaluronic acid concentration in their skin.

Various fine lines around the face including the crows feet, glabella, forehead, nasal labial and cheek creases are ideal areas for Restylane Silk. Another one of my favorite areas to treat with Restylane Silk is along the infraorbital to the lateral orbital area that is below the eye over to the hairline area, often thin, crepey and sometimes showing fine lines of volume depletion. Some women have very thin skin overlying the bony structures and many of the other fillers have a higher risk of lumpiness and can cause a Tyndall effect, or bluish look where the filler is visible through the thin skin.

Restylane Silk is used much like bovine collagen fillers in the past to address vertical lip lines, lip reshaping and mild enhancement as well as fine lines in various fine lines around the face. Restylane Silk's advantage is it lasts about double the duration depending on the patients skin status and location of product placement. 

It seems that we have gone full circle with availability of tissue fillers. Our focus went from chasing lines to plumping, volumizing and lifting and then back to the old way, filling lines softly and naturally in order to address needs of patients whose concerns are fines lines around the lips and face, lip reshaping and subtle enhancement.

When using the Restylane Silk to primarily address superficial fine lines one to two syringes can cover a lot of ground.  Adding Restylane Silk can be the ultimate. finishing touch to a revolumized and contoured rejuvenated face.

A New Solution for Double Chins
June 9, 2015 10:22 AM by Mina Grasso
Men and women often complain of disliking their profile due to their undesirable "double chin" or fullness of their neck due to submental and submandibular fat deposits under the chin or jawline. This condition is usually associated with genetics, aging and/or weight gain. It may be seen in patients within their ideal weight. The appearance of neck convexity or fullness negatively impacts these individuals, and they are often perceived as heavy or older.

Many patients assume that surgery is the only option. Now, these unmet needs can be addressed using a non-surgical option with injections to destroy fat cells. Injection of deoxycholic acid into the submental fat causes a denaturation of the fat deposits and dissolves the fat ,which allows the body to absorb it. This results in non-surgical contouring and sculpting of the neck. It is a procedure that we along with many other clinics have performed with variable results using deoxycholic acid compounded from various pharmacies.

Deoxycholic acid is produced in the body and helps the body absorb fats. Deoxycholic acid is a cytolytic drug. When it is injected into fat cells, it destroys the cell membranes. Practitioners must be properly trained to inject deoxycholic acid.  Accidental injection into surrounding tissue can cause destruction of those cells as well for instance surrounding muscle and nerve cells.

Deoxycholic acid will now be available for the first time as an FDA approved submental contouring injectable drug called Kybella. Kybella has undergone clinical studies for safety and effectiveness. Over 20 clinical trials with more than 1600 patients treated yielded high patient satisfaction. The anticipated arrival will be later this month. Kybella is the first and only approved non-surgical treatment for reduction of submental fullness or convexity. 

An ideal candidate for the treatment of the "double chin" with Kybella is a patient within their ideal weight with fullness of the neck, which is resistant to diet and exercise. Practitioners can customize the number of treatments to their patients according to the amount of submental fat. Most patients will require 2-6 treatments.  After desired reduction, patients usually will not require re-treatment. An anticipated concern may be residual skin laxity, but the inflammation caused by the Kybella may cause variable degrees of tightening, so a secondary tightening procedure may not be required after the series of injections.

The injections elicit minimal pain response, but due to inflammatory changes of the fat cells initial swelling post-injection can be expected and may last approximately 2-5 days, so some down time may be expected. Other adverse reactions may include  bruising, pain, numbness, erythema or formation of small areas of firmness at or around the injection site. Also the area may remain slightly more sensitive to touch for several weeks. Most of the adverse reactions were reported to be mild.

Décolleté’/Cleavage Rejuvenation
May 26, 2015 10:15 AM by Mina Grasso
Warm weather brings out more revealing outfits that show off arms, the décolleté/cleavage, back, legs and midriffs. Patients are becoming more aware of sun protection, skin care and anti-aging measures for the face, but many times stop there. The chest or décolleté/cleavage accumulates sun damage over a lifetime, and blotchy mottling, discoloration with brown spots, redness, veins, skin texture irregularities, fine lines and wrinkles develop. With the loss of collagen and elasticity as we age and accelerated with sun exposure, our body positioning such as when sleeping can contribute to the formation of certain creases and lines in the décolleté. 

Tank tops and revealing necklines can still be enjoyed using some anti-aging, rejuvenating measures. It's important to avoid or minimize further damage using sun protection. Skin care utilizing SPF and a combination of retinoids, bleaching agents, vitamin C, green tea, alpha hydroxyl acids, peptides and growth factors on a regular basis has been proven to improve skin quality and reverse signs of sun damage.

Many aesthetic treatments have also been beneficial in treating sun damage including but not limited to microdermabrasion, chemical peels, microneedling alone or with platelet rich plasma (PRP) to regenerate more youthful collagen using the patient's own growth factors to stimulate repair.

Light and laser devices are commonly used. Intense pulsed light (IPL) or Photorejuvenation can treat sun damage targeting red and brown discoloration as well as texture. Patients who have received a series of treatments have been reported to show more youthful gene patterns by skin biopsy. More stubborn pigmentation can be reduced with lasers that specifically target pigmented lesions. Ablative laser resurfacing such as fractional CO2 laser can effectively improve the texture of the skin by removing damaged skin and stimulating growth of new collagen in the cells and improving elasticity

Neuromodulators such as Botox and Dysport is a popular request for improving the appearance of lines and wrinkles as well as use of fillers such as hyaluronic acids to fill deeper lines and wrinkles. I have used bioactivators such as Sculptra (PLLA) to plump and improve skin quality by stimulating the patient's own collagen.

Patients desire skin tightening. The modalities we have used were primarily non-invasive radiofrequency. These non-invasive no-downtime include monopolar radiofrequency such Thermage or bipolar radiofrequency such as Viora Reaction. The radiofrequency is delivered to the surface of the skin, stimulates tissue contraction and new collagen growth resulting in tightening of the skin gradually over time without limitation of the patient's activity. The future looks promising for use of injectable RF such as ThermiTight RF for minimally invasive skin tightening of the décolleté and lifting of breast tissue without incisions.

Multiple treatments may be required depending on the age of the patient when starting treatment, skin type, hormonal status, skin condition, sun habits, therapeutic and maintenance skin care and follow-up treatments. Patients can look forward to reduction of some of the sun damage that has accumulated over the years and be able enjoy younger more vibrant looking skin in their tank tops and revealing necklines.
Non-surgical Facial Enhancement of the Upper Face
May 12, 2015 11:39 AM by Mina Grasso
Beauty of the upper face can be enhanced significantly using non-surgical techniques with neuromodulators and tissue fillers. Since the FDA approval of Botox for frown lines over a decade ago, patients have been well aware of the benefits of neuromodulators to improve the appearance of frown lines, crows feet and horizontal forehead lines. Typically patients think primarily of using neuromodulators to enhance the forehead but are not very aware of the benefits of adding volume to the forehead.  

When patients are first treated with neuromodulators, they experience a "wow" with the results. As the natural process of aging takes place, loss of collagen and elasticity as well as loss of volume of the upper face requires the addition of tissue fillers to not only reduce the appearance of wrinkles but to return volume and shape to the area.

Patients are familiar with tissue fillers in the nasal labial folds due to the ads and brochures that circulate with images of the "parentheses. Since Sculptra, a collagen activator and now the newest hyaluronic acid, Voluma, was introduced, awareness in a more global approach to the face is increasing in popularity. An area that had been limited to neuromodulators for most practitioners is the forehead.  Volume loss contributes a great deal to the loss of the "golden" proportions and shape to the forehead. When the forehead is rejuvenated and volume is replaced, a more youthful, well-rested face with natural appearing transitions is the outcome.

When patients start to express concerns of neuromodulators not working as well as they used to, especially in the upper face and around the eyes, it becomes important to evaluate volume loss in these areas.  Frequently patients report that these areas are their last concerns, because their hair covers their temples and their bangs usually can cover their foreheads. Patients who have experienced ptosis of their eyelids who avoid neuromodulators in the forehead are more open to discussing this option. 

A clear understanding of ideal shape and proportions of male and female genders and the concept of global facial rejuvenation in critical in educating the patient on how we can help them to look more refreshed, youthful and natural safely. When we understand what the ideal proportions of beauty, we can reflate and contour the face and deliver optimal results. Tissue fillers can treat glabellar or horizontal creases, temporal hollows, enhance eyebrow and forehead re-shaping.

As a practitioner, understanding the anatomy of the face with respect to critical structures such as facial arteries, veins and nerves is important and enhances our confidence in providing a safe treatment minimizing pain and bruising. The experience for the patient is equally important as the outcome of results.
April 28, 2015 9:04 AM by Mina Grasso
For several months, we have been offering a minimally invasive skin tightening procedure called ThermiTight injectable RF that allows us to tighten skin of the jowls and neck, upper arms, abdomen, knees and thighs. This device uses the ThermiRF radiofrequency platform for various applications with unique real-time precise thermoster controlled mircro-invasive and non-invasive treatments.

The most recent application is called ThermiVa. ThermiVa was introduced at the IMCAS World Conference as a breakthrough in non-surgical vaginal rejuvenation.

Years ago we offered laser vaginal rejuvenation in our clinic by OB/GYNs specialized in performing the procedure, creating a more aesthetic appearance, but it required surgery and involved downtime. The procedure is still performed today, but if given an option, most women would prefer a non-surgical approach without downtime.

ThermiVa requires a specific vulvovaginal radiofrequency applicator to work with the ThermiRF platform. ThermiVa is completely performed non-surgically and requires no anesthesia. There is no downtime required after the procedure. Gentle gradual heating allows the patient to tolerate therapeutic temperatures that stimulate collagen contraction and therefore skin tightening resulting in vulvovaginal rejuvenation. It's like performing a vulvovaginal "face lift" without surgery in an aesthetic clinic.

Vulvovaginal laxity, dryness, tissue stretching, nerve impairment, incontinence due to aging and loss of collagen are common issues that many women learn to live with and are often not discussed. Some women never even bring up these issues to their gynecologist thinking that nothing could be done anyway. Unfortunately, any one of these issues can make a woman feel less attractive, reduce her sense of well-being, impede sexual satisfaction and interfere with intimacy.

Red Alinsod, MD, FACOG, FACS, ACGE, a global leader of temperature controlled RF in vulvovaginal laxity, presented the findings of a pilot study using the ThermiVa procedure to treat vulvovaginal tissue using temperature controlled radio frequency. Alinsod is the Chairman of the ThermiGyn Women's Health Advisory Clinical Board.

Alinsod's study results showed both vulvar laxity and vaginal laxity improved significantly for all patients after the first treatment and continued to improve after the third and final treatment. In addition, participants reported improvement in sexual satisfaction, vulvovaginal tightening as well as improved vaginal moisture and improved continence as a result of the treatment.  Dr. Alinsod noted, "The potential for a simple and safe temperature controlled RF device to treat vulvovaginal laxity, atrophic vaginitis, mild to moderate stress incontinence, overactive bladder, and orgasmic dysfunctions holds great promise and could be transformational.

The aging process affecting the vulvovaginal skin treated with a non-invasive method can now be provided as a simple no downtime office procedure to those seeking aesthetic enhancements and may provide improvement in sexual enhancement and sense of well-being.

Smoother, Tighter Skin without Downtime
April 14, 2015 11:18 AM by Mina Grasso

Over the last decade we have seen a tremendous growth in the development of non-invasive, non-surgical devices that promote skin tightening. The latest addition to our armamentarium of rejuvenation includes the ThermiSmooth procedure, which utilizes external radiofrequency energy for gentle, precise epidermal heating. It’s the only system that the temperature can be adjusted for the specific area of concern.

When the skin temperature is sustained to approximately 40°-42°C, an inflammatory response is created and stimulates the fibroblasts in the tissue to produce collagen. The heat stimulates collagen contraction that results in tighter, smoother skin over time. A precise amount of heat is required while appropriate technique is used to maintain the temperature for 5-7 minutes over a small zone. Multiple zones such as the forehead, around the eyes, cheeks, around the mouth, jowls and neck can be treated. 

The most popular area requested is around the eyes. This is an area that usually reveals our age, and there are not a lot of treatment options that address the skin quality under the eyes and eyelids without downtime.   This is an option for patients who cannot afford the downtime of a more aggressive ablative fractional CO2 laser resurfacing treatment. “Social downtime” is many times the reason for patients to avoid certain treatments. Now we have ThermiSmooth, which can be performed within a few minutes, and normal activities can be resumed immediately. Patients can even be treated during their lunch break.

During the ThermiSmooth procedure, a gel is applied to the skin. The hand piece is usually moved in a circular motion over the gel until the target temperature that is set (usually 42°C) is reached, and then a faster gentle sweeping motion is applied to sustain the temperature while keeping the patient comfortable. Sustaining the temperature for 5-7 minutes is key to the collagen stimulation. 

Four to six treatments two weeks apart are usually recommended depending on the patient’s desired results. Although some improvement may be seen immediately after treatment, continued improvement in skin thickness and skin quality is observed over several months after the ThermiSmooth sessions. 



About this Blog

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