Dr. Tina Alster & Dr. Neelam Khan

There are several types of tattoos. The most popular ones are the professional tattoos, which are the hardest to remove because the amount and depth of ink that’s injected is great. Another type is the amateur tattoo, which are those done in the “back alleys” with carbon based ink. Then you have cosmetic tattoos, such as eye liner and lip liner. Medical tattoos mark radiation ports. Traumatic tattoos are the ones that if you fall on the road and get a road rash you can get gravel embedded in your skin and it looks like your skin has been tattooed. The hardest to remove is the professional tattoos because there’s just so much more ink, which increases the number of treatments that it takes to remove them. We typically use lasers because we can use certain laser wavelengths like a Q switch, which is very brief pulses of red and infrared light. Alexandrite and Yag lasers are the shortcut to get rid of the tattooing. An amateur tattoo, or a traumatic tattoo that doesn’t have as much ink in there, may only take two to four treatments. The lasers hone in on the tattoo ink and blast it. The only other way to remove tattoos is to cut them out then you’re substituting one mark with a pretty significant scar.

We’ve been trying to use laser lipolysis while doing liposuction. Instead of sucking it out you’re basically melting the fat directly. I do noninvasive fat elimination and there are now three different ways you can do it. One is using Zeltiq, cool sculpting using cryolipolysis that freezes the fat cells and makes them die. You can eliminate the fat from the outside in so There’s a new device called Bella Contour. It has negative pressure, diode laser energy and radiofrequency. It feels like a warm bath but repetitive treatments have been shown to make the fat cell leaky so it drains the fat cells of fat. So the fat cells are still there but they are like deflated balloons. So if you go through a series of these treatments you will definitely slim down and definitely have a better body contour. However, once again, you have to maintain your new look.Another thing that people will body contour with is Thermage. That’s using bulk tissue heating but it’s really not getting the fat as much as it’s contouring the dermis above the fat so it makes it lie more smoothly.there’s no recovery. Those fat cells do not come back because those fat cells are dead. Once those fat cells die they won’t re-grow, however, if you still have fat cells that are adjacent to it or in another area and you gain weight those fat cells are going to increase in size. It’s much like with liposuction, you get rid of some and you still have some there, if you gain weight it’s going to look like it came back and redistribute. All things being equal, if you maintain your body weight it’s gone.

You can typically treat those in the same appointment and the best lasers for those are called pulse dye lasers. I think the Synergy is a good one because it has the ability to treat multiple size vessels all on the same visit with the same laser. Typically the treatment takes a few minutes to do and afterward people look a little bit pink for maybe an hour or so but after that there’s really no downtime. You can go right back to your regular activities. To get the right response we usually will do anywhere between three and five in a row, roughly at six week intervals. It doesn’t really hurt either, it’s just a little snappy, like the snapping of a rubber band but it’s quick and doesn’t require pain control.

For brown and sun spots on the surface my favorite peel is called the Vitalize Peel. It’s a combination between an alphahydroxy glycolic peel and also retinoic acid so it really helps to peel the surface of the skin. It does a nice job to refresh and restore a healthy glow and even out skin tone and there’s not too much recovery time. The skin will start to peel two days after the solution is applied and then it will peel for two days. The whole process is done in about four to five days and during the time of the peel it’s not raw skin, it’s just very dry. Once the whole process is over the skin looks nice and refreshed.

For old acne scars one of the best acne treatments is called Fraxel re:store. It is done in a series of treatments to try to stimulate collagen to fill up the scars. Typically, depending on the severity of the scars, we may do anywhere between three and six treatments about a month apart. After each you are pink for a couple of days but you can cover it with makeup.

Quite frankly I think that sometimes it’s easier to treat older acne scars that are stable because they’re not changing on you. My favorite way to treat them is with lasers, either ablative or non-ablative fractionated resurfacing. The laser does two things that are helpful with scars. One thing it does, as the name describes, is resurfacing, literally vaporizing the top layer of skin. The second thing it does is allow for the skin below to be contracted. When collagen is heated above 60 degrees centigrade, it contracts, transforming into a tightened scaffold on which the new skin is built. You’re basically recovering the skin but you’re also building the skin from below and that’s how it helps the acne scars.

In my experience the best nonsurgical option on the face, to help tone and tighten the skin is Ulthera. It’s ultrasound that essentially seeps through the surface of the skin and targets the support structures, heats them up and over about three months time it stimulates collagen to help lift and tighten. There’s no cutting, no downtime and no recovery time involved. The results are delayed about three months. Typically people do one treatment and then they wait three to six months for all the collagen to be stimulated and the tightening effects to take place. At that point they may choose to do another treatment for additional improvement but not everybody needs to do. The disadvantage of the nonsurgical approach is that the results are not as long lasting. You expect to see the results of a facelift for potentially ten plus years, the non surgical Ulthera option is most likely going to last about two to three years.

They’re both nonsurgical tightening options. Thermage uses radiofrequency to deliver the heat. The heat placed with Thermage is not quite as deep as you can get with the ultrasound, which is the type of energy used in Ulthera. They both put heat into layers of the skin. They put heat under the surface to stimulate collagen and tighten the skin. Thermage does a nice job on body parts. It does a nice job to help tone up some of the lax skin on the arms, the legs and abdomen. The main difference is that ultrasound does the job a little bit deeper.

Some are spider veins and some are so called “broken capillaries.” They can be removed but sometimes they’ll require different lasers. The bigger spider veins on the body may require a different laser than the smaller broken capillaries on the face. Usually it will require more than one treatment for the best response and treatments are often done about six weeks apart.

People trying to get a more permanent solution to their thin lips may go for an implant. But in my opinion that’s not a great option because it often can look stiff and unnatural.

For one Botox injection the clinical results will normally last three to six months. If you want continued improvement, or if once the effect of this dies down, it will become necessary for you to have another treatment to maintain the cosmetic effect.

Permanent fillers include a non-absorbable substance like Artefill to correct a defect in the skin such as a pock mark or scar. It can also be used to fill in wrinkles, however because wrinkles are dynamic, or change, permanent fillers are not as advisable as collagen-stimulating fillers including hyaluronic acid fillers like Juvéderm and Restylane. Hyaluronic acid filler stimulates collagen, which will enhance the longevity of the filler and improve the clinical results. They are better for wrinkles and for a lot of acne scars rather than just a single scar. If somebody has just one indentation from a pock mark or an indentation of a scar then I like to use a laser. But those are the type of things where permanent fillers are really good for isolated indented scars whereas collagen stimulating fillers which include the hyaluronic acid fillers, like Restylane, Perlane and Juvéderm, are good for all those areas that change because of aging.

The answer here may be all of the above. If you do not have wrinkles at rest and you want to minimize the dynamic wrinkling of your brow, then using Botox or Dysport, a neurotoxin alone, would be all that you need. If you have lines that are there even at rest, when you are not actively frowning or moving your face, then you will likely need both a toxin and a filler. What I tell people is that if they have skin discoloration and a lot of wrinkling in areas that are not necessarily dynamic, say across your cheeks, then I think laser resurfacing is a nicer way to tighten and resurface the skin to give you an overall more youthful look.

If it’s just sun damage and brown spots without wrinkling, topical lighteners and brighteners like Elure or kojic acid-containing things and Vitamin C can be helpful. If you want to come into the office to speed the lightening, chemical peels are super. The Vitalize Peel by TNS or revitalize peel are options that contain resorcinol, glycolic and lactic acid. There are TCA (trichloroacetic acid) peels as well. And if you have wrinkles in addition to the hyperpigmentation then you might want to add in some of these fractionated lasers, ablative or non-ablative, but that would not be my first choice just for sun spots and hyperpigmentation.

I always tell people they’ll see the most change between one and three months, but it takes up to six months to see the final effect, which can last as long as a facelift but without as much tightening as you get with a facelift. You get some tightening and lifting and that becomes your new starting point. We don’t know how long it lasts but it’s not like you’ll be coming in every year starting at ground zero.

I am starting to do something new called illumiWave. This is a series of treatments, usually performed once a week or as many as twice a week for a total of 36 treatments. This is good for everyone and you come in and sit under the device, which looks like a heat lamp and is directed at wherever you’re losing hair (mostly around the scalp). It takes about 20 minutes, and it stimulates new hair growth. Everybody in the studies showed that hair loss was eliminated so it stabilizes the hair loss. And 40 percent of the people then noticed that there was an increase in hair re-growth. That’s not bad for something that is totally noninvasive.

It stimulates the cells around the hair follicles to restart, it’s like rebooting your computer, in fact it will send the signal to your hair follicle to start producing hair. These laser lights do increase the vascular network in the area of your scalp. You end up stimulating cells to create hair. The drawback with the illumiWave and the Bella Contour, is that you have to keep doing it. However, you don't have to do it as often as time goes by. Once you reach where you want to be, maintenance is the order of the day.

If you don’t mind looking bad for a while until it looks really bad then wait until you have your necklift. If you don’t ever want it to form, there are things you can do to prevent it from getting that bad. And depending on if there are bands there you can do a little Botox or Dysport. You can do Ulthera or even Thermage and tighten that area so that it never gets the big wattle. Do it preventively or right when it starts happening and that becomes your new starting point. Younger people don’t mind doing the maintenance, older people grew up waiting until it gets really bad and they have to get a facelift.

We see a lot of acne in women in their 40s 50s and even 60s. It’s certainly a common problem and the best approach to treating it depends on the cause. Some people have hormonal acne that doesn’t respond to traditional acne therapies. Whether it’s ‘stage of life’ acne varies by individual. Some clues to hormonal acne would be cystic flares that occur just before the period and those are treated by hormonal therapies whereas traditional acne, or inflammatory acne, can be treated in later stage of life just as it is in teenagers. We just individualize the treatment to the cause. There is certainly a treatment and it needs to be targeted to the specific cause and a consultation would be the best first step to determining the cause. Sometimes it requires blood work and a full evaluation to determine whether hormonal therapy is needed.

The question depends on the type of injectable being used. Botox, Dysport and other neurotoxins tend to last three to four months and we recommend three or more times per year to maintain the look. For injectable fillers they can last anywhere from six months to several years depending on the agent used, and there are permanent agents available as well.

Consultation with an expert is the most important in this situation because there are different types of wrinkles. The first type is called dynamic wrinkles which means that when you wrinkle a muscle it creases the skin and then when you relax the muscle the wrinkle disappears. There are other types of wrinkles called etched or folds and those typically appear at rest whether or not you’re wrinkling a muscle and those are more difficult to treat. They typically require a combination of injectables and possibly laser resurfacing.

Liquid facelift is a term used to describe a procedure where volume is restored to different areas of the face, using an injectable filler to fill in those areas of lost volume. And the final result appears something like a lift once you’ve restored the volume to all the areas. So we’re not actually cutting; we're restoring the volume in the different areas of the face. The length of the results depends on the injectable used. Fillers can last anywhere from six months to several years or even be permanent depending on what was used.

It’s always a combination of restoring volume, resurfacing texture and filling those grooves and folds and then finally tightening the skin. Typically we use Botox to relax the muscles that are creating the dynamic line. We use the injectable fillers to fill grooves and folds and also restore volume to areas of atrophy where the volume has been lost. And then finally we use tightening devices to actually remodel the collagen or tighten the fascia underneath the skin. And we use lasers over the surface of the skin to smooth the pores and fine lines and to even out red blood vessels and brown spots.

It’s impossible to remove cellulite. At best we can smooth the appearance of cellulite somewhat. Surgery cannot address that area so it’s a very difficult area to treat. To smooth it, you can use radiofrequency, or ultrasound devices like VelaContour. There are also combination devices that combine massage, infrared light and radio frequency and there are newer technologies being developed all the time. VelaShape and VelaSmooth would be a combination device.