Dermatologists San Diego, CA

• BOTOX AND DYSPORT (www.botoxcosmetic.com) (www.dysport.com)
• RESTYLANE AND JUVEDERM (www.juvederm.com) (www.restylane.com)
• RADIESSE (www.radiesseusa.com)
• ARTEFILL (www.artefill.com)
• COLLAGEN
• CHEMICAL PEELS
• SCLEROTHERAPY
• LASER HAIR REMOVAL (www.candelalaser.com)
• V-BEAM LASER (www.candelalaser.com)
• FRAXEL RE:PAIR LASER (www.fraxel.com)
• PHOTO-DYNAMIC THERAPY
• REMOVAL OF SKIN TAGS, SEBORRHEIC KERATOSES, AND SEBACIOUS HYPERPLASIA

BOTOX AND DYSPORT

BOTOX and DYSPORT are purified muscle relaxing agents.  Motor nerve endings are areas where nerves connect to muscles.  When the brain sends a signal for muscle contraction, this signal is transmitted to the muscle through the release of a substance called acetylcholine at the motor nerve ending.  BOTOX and DYSPORT block the release of acetylcholine, therefore blocking the muscle contraction.

Repeated facial muscle contraction is a contributor to some facial wrinkles, called dynamic wrinkling.  These lines are often found between the eyebrows from frowning, around the eyes from smiling, and on the forehead from raising the eyebrows.  BOTOX and DYSPORT treatment can relax these muscle movements, and thereby smooth out the lines and wrinkles.

BOTOX and DYSPORT are administered in the office with small injections into the culprit muscles.  BOTOX effect usually appears gradually within 2 to 14 days.  DYSPORT may have a quicker onset of action.  Results usually last between 2 to 6 months.  As muscle movement returns, repeat treatment can be done.  After the injections, patients are asked not to lie down for the next 4 hours, or massage the treatment sites.  It is also recommended that patients continue to contract the treated muscles a few times each hour for the remaining day.

Minor side effects include possible bruising at the injection sites, and slight discomfort with injection.  Rarely, if some BOTOX or DYSPORT were to relax the muscle which elevates the eyelid, eyelid droop (ptosis) may occur.  Usually this droop will diminish after a few weeks.  Some patients, after treatment of the forehead, may experience a heaviness of the eyebrows.  Your practitioner will evaluate you before the treatment to see if your brows and forehead would be more at risk.  Some patients will not respond to the BOTOX or DYSPORT treatment.  Your practitioner will ask you about your medical history prior to treatment.  Patients with certain medical conditions, such as Myasthenia Gravis, may not be good treatment candidates.

Although extremely unlikely, the FDA requires patients to be informed of the following BOTOX or DYSPORT risks:  problems with swallowing, speaking, breathing; muscle weakness; loss of bladder control; death.  These risks have never been reported with cosmetic use of BOTOX or DYSPORT.
(www.botoxcosmetic.com)
(www.dysport.com)

RESTYLANE and JUVEDERM for wrinkles and scars

Injection of Hyaluronic acid can be used to improve facial wrinkles and depressed scars, by filling in sunken areas of the skin. Hyaluronic acid is a polysaccharide molecule naturally found in the extracellular space of all tissues in all vertebrates. Its function is usually to provide a matrix to provide volume and support to cells and tissues. Restylane and Juvederm are specific brands of Hyaluronic Acid, and are FDA-approved for use in facial wrinkles.  Hyaluronic Acid is introduced into the affected area by injection. The purified Hyaluronic acid thus stays in the desired area of the skin, and “fills” it in. Water binds to the molecule, and helps provide volume. Different conditions in which areas of the skin are sunken in or depressed respond well to this treatment. Common conditions include wrinkles, such as around the cheeks, lips, frown lines, or smile lines between the upper lip and cheeks. Flattened or less defined lip borders can also be plumped up with Hyaluronic Acid. Depressed acne scars can also be filled in. Pitted or “ice pick” acne scars do not respond well. A treatment typically lasts more than 6 months, before the body naturally reabsorbs the injected Hyaluronic acid. At that time, repeat treatment can be done, if desired. Unlike collagen injection, Hyaluronic Acid treatment can be performed without a prior skin test.

The actual Hyaluronic Acid treatment involves injections with a fine needle directly into the desired areas. Topical anesthetic can be placed on the area prior to treatment, and you can ask your physician beforehand. Alternatively, at the time of treatment, a nerve block can be administered, which involves injection of a local anesthetic into the areas of the gums. Your practitioner will determine the amount and type of Hyaluronic Acid to be used, depending upon the defect to be treated. There may be some local bruising, similar to having blood drawn. There is usually some slight swelling and redness, lasting approximately 2-3 days. Cold compresses may be applied. Other less common risks include allergic reaction, formation of scab or scar, and light or dark discoloration at injection sites, or infection. There is a remote possibility that Hyaluronic Acid can be injected into a blood vessel causing blockage. There is always the possibility that you will not notice improvement. Prior to treatment, your physician will take a medical history, to be sure that you can proceed with treatment. You should let your physician know if you have a history of cold sores. You should avoid blood thinning medications such as aspirin, ibuprofen, St. John’s Wort, or high doses of vitamin E, for one week prior to and after treatment.
(www.juvederm.com)
(www.restylane.com)

RADIESSE for wrinkles and volume correction

Injection of Radiesse, calcium hydroxylapatite microspheres in a water based gel carrier, can be used to fill in deep facial wrinkles and depressed scars.  Calcium hydroxylapatite is a naturally occurring substance found in bones of all animals, providing a matrix to support muscles and joints.  It has been used for decades in safe clinical applications and is now FDA approved for improving the appearance of moderate to severe facial wrinkles including the Nasolabial Fold.

Radiesse is introduced into the affected area by injection.  The calcium hydroxylapatite forms a “scaffold” that surrounds the natural growth of the patient’s own collagen.  Radiesse treatment typically lasts 9-24 months before the body naturally reabsorbs the injected calcium hydroxylapatite.  At that time, repeat treatment can be done, if desired.  Like Restylane and Juvederm, Radiesse treatment can be performed without prior skin test.

The actual Radiesse treatment involves injections with a fine needle directly into desired areas.  Topical anesthetic can be placed on the area prior to treatment. Alternatively, at the time of treatment, a nerve block can be administered, which involves injection of a local anesthetic into the area of the gums.  Your physician will determine the amount of Radiesse to be used, depending upon the defect to be treated.  There may be some local bruising, similar to having blood drawn.  There is usually some slight swelling and redness, lasting approximately 2-3 days.  Cold compresses may be applied. Other less common risks include allergic reaction, formation of scab or scar, and light or dark discoloration at injected sites, or infection.  There is a remote possibility the Radiesse can be injected into a blood vessel, causing blockage. There is the chance that the Radiesse can feel “lumpy.”  You may be able to feel the area where Radiesse was injected for some period after injection.  Over time, the injected area will feel more and more like your own tissue.  There is always the possibility that you will not notice improvement. 

Prior to treatment, your physician will take a medical history, to be sure that you can proceed with treatment.  You should let your physician know if you have a history of cold sores, so prophylactic medication can be prescribed.  You should avoid blood-thinning medications such as aspirin, ibuprofen, St John’s Wort, or high doses of vitamin E, for one week prior to and after treatment.   For 24 hours after treatment, avoid significant movement or massage of the treated area.  Do not apply makeup, and avoid extensive sun or heat exposure.  Radiesse can be seen in X-rays and CT scans, so it is important that you inform your doctors about your Radiesse, if radiologic tests are ordered.  Even though Radiesse can be seen in X-rays and CT scans, there is not a high risk that it would cause your doctor concern.  
(www.radiesseusa.com)

ARTEFILL for permanent correction of wrinkles or volume restoration

Artefill is introduced into the affected area by injection. The Polymethylmethacrylate forms a “scaffold” that stimulates the natural growth of the patient’s own collagen. Artefill treatment should be considered permanent as the body does not metabolize or resorb the Polymethlymethacrylate, but continues to metabolize the collagen around the particles and at the same time produce new collagen, keeping the correction constant. As years go on and the facial skin gets looser, the correction will lessen and there is some chance the filler will move with the loose skin lower on the face, requiring additional filler to again plump up the wrinkles.

Arteill treatement requires a skin test to the collagen used to suspend the particles. This must be done a month or more before the Artefill injections. The particles themselves cause allergic reactions less than 0.1% of the time. The actual Artefill treatment involves injections with a fine needle directly into the desired areas. Topical anesthetic can be placed on the area prior to treatment. Alternatively, at the time of treatment, a nerve block can be administered, which involves injection of a local anesthetic into the area of the gums. Your practitioner will determine the amount of Artefill to be used, depending upon the defect to be treated. There may be some local bruising, similar to having blood drawn. There is usually some slight swelling and redness, lasting approximately 2-3 days. Cold compresses may be applied. Other less common risks include allergic reaction, formation of scab or scar, and light or dark discoloration at injection sites, or infection. There is a remote possibility the Artefill can be injected into a blood vessel, causing blockage. There is always the possibility that you will not notice improvement. Prior to treatment, your physician will take a medical history, to be sure that you can proceed with treatment. You should let your physician know if you have a history of cold sores. You should avoid blood-thinning medications such as aspirin, ibuprofen, St. John’s Wort, or high doses of vitamin E, for one week prior to and after treatment.

We generally do not inject Artefill filler in patients who have not experienced the results of other fillers such as Collagen, Restylane, Juvederm, or Radiesse. This is because the results with Artefill are permanent, and although most people see impressive improvement, we do not want to treat someone who may decide that the long term result of fillers are not for him or her. We would suggest you try one of the other fillers first, and then switch to Artefill if you are so happy with the results that you want the long term results Artefill will give you.
(www.artefill.com)

COLLAGEN for wrinkles and scars

Collagen protein can be used to improve facial wrinkles and depressed scars, by filling in sunken areas of the skin. Collagen is a protein found in many tissues of the body, and generally provides structural support. There are different collagen types in the skin, bone, cartilage and tendon. Collagen has a fiber-like structure, and can “weave” together to form a network or framework. In the skin, it provides texture, resilience, and shape. Our practice uses Zyderm brand collagen, which is purified collagen from cow skin.
Zyderm collagen is introduced into the affected area by injection. The purified collagen thus stays in the desired area of the skin, and “fills” it in. Different conditions, in which areas of skin are sunken in or depressed, respond well to this treatment. Common conditions include wrinkles, such as around the cheeks, lips, frown line, or smile lines between the upper lip and cheeks. Flattened or less defined lip borders can also be plumped up with collagen. Depressed acne scars can also be filled in. Pitted or “ice pick” acne scars do not respond well. Zyderm collagen treatments typically last between 2 to 6 months, before the body naturally reabsorbs the injected collagen. At that time, repeat treatment can be done, if desired.
To begin the collagen treatment, the first step is to have a skin test. There is a possibility that you will be allergic to the collagen, and the skin test is to avoid injecting allergic patients, as this could result in allergic reaction resembling a persistent insect bite, lasting 2 to 6 months. All patients must undergo the skin test. The first one is a small collagen injection, usually into the forearm, which is monitored for 1 month for any reaction or redness. The second test injection can be into the arm or hairline, and again is monitored for 1 month. If you have had prior test injections of collagen treatment without reaction, please let your practitioner know.

The actual collagen treatment involves injections with a fine needle directly into the desired areas. Topical anesthetic can be placed on the area prior to treatment, and you can ask your practitioner beforehand. Your practitioner will determine the amount of Zyderm collagen to be used, depending upon the defect to be treated. There may be some bruising, similar to having blood drawn. There is usually some slight swelling and lumpy appearance, lasting approximately 1 day. Other less common risks include allergic reaction (even after 2 negative test doses), formation of scab or scar, and light or dark discoloration at injection sites. There is a very remote possibility that collagen material can be injected into a blood vessel, causing blockage. There is always the possibility that you will not notice improvement. Prior to treatment, your practitioner will take a medical history, to be sure that you can proceed with treatment. If you are on certain medications, such as prednisone, your practitioner may wait until you are off the medication prior to treatment. Patients allergic to lidocaine (local anesthetic) should not be treated. There is controversy whether there is a link between collagen treatment and autoimmune diseases. Please discuss this with your practitioner, particularly if you or your family has a history of autoimmune disease.

CHEMICAL PEELS for fine wrinkles, uneven pigmentation, skin rejuvenation, or acne

Chemical peels come in many different types and strengths, but the main action of peels is to remove the top layer of the skin, and allow the bottom layers to rejuvenate and grow in.  The components of the skin from top to bottom include the stratum corneum, which is the topmost dead layer, the epidermis, which is the first living layer and the layer most visible to the eye, the dermis, which is the middle, structure-bearing layer, and the deeper subcutaneous fatty tissue.  Light chemical peels usually remove the stratum corneum.  Deeper peels can penetrate into the epidermis.  The risk of penetrating too deeply into the dermis is possible permanent scarring.  Some publications have reported that chemical peeling can actually stimulate new collagen growth in the dermis.  Peeling can remove excess stratum corneum, which can appear as dry lusterless skin.  Peeling can also remove excess dead skin from plugged up hair follicles.  Uneven pigment in the epidermis, such as from sun damage, can be peeled away along with the epidermis, to allow a more uniform epidermis to grow in.

The following is a brief discussion of various peels offered by our practice.  You should discuss with your practitioner your goals for skin improvement.  Depending upon your skin type and desires, the proper treatment plan can be suggested.

Glycolic acid is an alpha-hydroxy acid derived from sugar cane.  Peels can be performed with glycolic acid ranges from 20 to 70 percent.  Peels are applied to the skin, and are usually left on for anywhere between 1 to 10 minutes, and patients experience mild to moderate stinging and burning.  These peels can penetrate into the stratum corneum and epidermis, depending upon strength and application.  Directly after the peel, there is usually light redness, and peeling skin for the next few days.  Patients can usually resume their normal activities upon leaving the office.  These peels generally do not achieve the desired goal after only 1 treatment.  Usually, glycolic acid peels are done in a series, such as every 1 to 4 weeks, for about 6 total treatments.  Your practitioner will discuss the appropriate plan with you.  Your practitioner may ask you to use home products containing glycolic acid and/or hydroquinone to treat the skin before and/or after the peels.  Prior to the peels, you may be asked to discontinue use of certain medications such as Retin-A.  These peels can improve skin texture, skin pigment, acne, mild acne scarring, and mild sun damage.

Beta Lift peels are a brand of peel composed of salicylic acid, a beta-hydroxy acid.  The peels are available in 2 strengths.  The application of the peel is similar to the description of the glycolic acid peel, except that this peel is not timed.  The patient experiences mild to moderate tingling and burning, which stops by itself after approximately 3 to 5 minutes.  These peels can be done for the same conditions as for glycolic acid peels.  Because the beta-hydroxy acid penetrates well into the hair follicles, it is useful to treat the plugged pores in acne.

Tri-chloro-acetic acid (TCA) peels can range from light peels similar to glycolic acid peels, to deeper peels similar to resurfacing treatments.  20% TCA peels can be performed for skin rejuvenation, pigment irregularity, and skin roughness.  At this lower strength, the peels can be similar to or slightly deeper than the glycolic acid peel.  In addition to redness and peeling, there may be some superficial erosions and crusts.  One way to deliver the 20% TCA peel is in a series of three, one week apart.  Each subsequent peel goes deeper, because of the skin removed at the prior week’s peel.  Deeper TCA peels can be done at concentrations greater than 20%.  The goal of the deeper peel is generally to treat moderately to severely sun damaged skin, or some acne scars.  Deeper peels can also treat some early actinic keratoses (precancers).  The deeper peel is usually performed once.  The patient experiences moderate to intense burning during the treatment, which lasts approximately 5 minutes.  Afterwards, the skin is red and has a whitish frost from the peeled skin.  The patient can expect some swelling, crusting, and drainage for about 1 to 2 weeks, during which time ointment dressings are being applied.  Patients generally will take some time off from their schedules for this treatment.  After the skin has healed, there may be some light redness for the next few months.  Patients may be prescribed antibiotics to take during the healing period.  Usually, prior to treating the complete area, your physician will perform some test spots first.  The deeper TCA peel may not be suitable for some patients with darker skin types, due to risk of pigmentation changes.

For all types of peels, it is important not to have excessive sun exposure for a few weeks before and after the treatment.  After the peel, it will be important for you to use careful daily sun protection.  Be sure to discuss your current topical medicines and creams.  If you are using Retin-A, Differin, or Tazorac, you may be asked to stop 1 week before the peel.  Be sure to tell your practitioner if you have had Accutane pills in the past (a medication for severe acne), as this treatment may cause difficulty with skin healing for up to 1 year after the last pill.  Also tell your physician if you have had cold sores (Herpes blisters), so that a treatment may be prescribed to prevent an outbreak after the peel.

Risks for all types of peels include light or dark discoloration (pigmentation), absence of desired effect, persistent redness, scarring, infection, and irritation to the eyes if they are exposed.  Risks generally are greater for the deeper peels.  Your physician will try to minimize the risks by carefully choosing the correct peel for you.  Some patients with darker skin may have higher risk of pigment side effects.

SCLEROTHERAPY for unwanted leg veins

Increased superficial leg veins, such a telangiectasias (spider veins), or larger varicose veins, are common. Often there is a family tendency, and they may be worsened by hormones (including pregnancy), prolonged periods of standing or sitting, being heavy, or certain underlying diseases. While many patients have no discomfort, some have itching, burning, or aching of these leg veins, and symptoms may worsen with menstrual periods. These superficial leg veins may be removed or closed without affecting the circulatory system in the body.

Sclerotherapy is a non-surgical procedure for closing unwanted superficial leg veins. A sclerosing solution is injected into the veins using a tiny needle. The solution can be a detergent (made specifically for sclerotherapy), irritant, or hypertonic solution (such as concentrated saline). Multiple small injections will result in some temporary stinging and localized swelling of the treated veins. Immediately after the procedure, tight compression stockings are worn continuously for 3-7 days.  This combination of injections and compression leads to gradual closure of the veins.  We recommend 20-30 mmHg medical compression stockings (thigh-high with gripper tops, or pantyhose).  If larger veins are treated, higher compression and longer wearing time may be needed.  Walking for 30 minutes per day, for at least one week following the procedure, will help speed the improvement, and help with any discomfort.

Temporary bruises are common, and will fade over 1-2 weeks, followed by gradual improvement of the leg veins.  Treated vessels become less defined, then gradually thinner, finer, and less apparent.  Sometimes, tan color develops, and the vessels may become darker, firm, or lumpy, especially if larger veins are treated.  This normal reaction will improve, though small amounts of tan pigment may occasionally persist.  Fading of the veins may be noticed at 1-2 months, but gradual fading will continue for 3-6 months after injections.  Multiple treatments are required for best results, usually 2-6 treatments spaced one to a few months apart.  We can’t eliminate all unwanted veins, or guarantee results, but most patients improve with sclerotherapy.  Usually 50-70% of veins will fade after multiple treatments.  Whether treated or not, most patients will continue to develop new veins, which may be treated periodically, as desired.  Continued use of support hose may help in prevention.

All medical procedures have some risks.  In addition to expected reactions already discussed, a small scab or open sore may occur at an injection site.  This will heal, but could leave a small scar.  Please call the office if any scabs or sores are noticed.  Occasionally, a network of tiny veins may develop around an injection site.  This is called “matting”, and the new veins often improve without further treatment.  If persistent, they may respond to additional injection or laser treatment.  Rarely, inflamed, painful veins (thrombophlebitis) may occur, and very rarely, blood clots in the deeper veins may occur, which have a remote chance of traveling to the lungs.  Allergic reactions to sclerosing solution are rare, but notify your practitioner of any allergies before the procedure.  You should also let your practitioner know if you suffer from thrombophlebitis, deep vein thrombosis, poor circulation, clotting disorders, history of pulmonary embolus, or swelling of the legs or feet.

Before you schedule sclerotherapy, a vein consultation appointment is necessary.  At that time, the practitioner will discuss your medical history, examine your leg veins, and let you know what specific treatment is recommended in your case.  In preparation for your treatment session, you should discontinue aspirin and non-steroidal anti-inflammatory medications for one week (consult your prescribing practitioner).  You should avoid sun exposure to the legs for a few weeks before and after the session, to minimize hyperpigmentation.  Wear loose clothing, and bring your compression stockings with you to the appointment.  After the session, you should be able to return to normal activity.  Laser treatment is also available in our office, however, only the tiny leg veins respond to laser, and most cases require additional treatment for best results. Larger varicose veins may have underlying venous reflux (abnormal blood flow), and other treatments such as surgery, endovenous laser ablation, or ultrasound-guided sclerotherapy might be recommended. These are not performed in our office, but we can refer you to appropriate physicians, if needed.  Sclerotherapy for leg veins, as performed in our office, is considered an elective, cosmetic procedure, and is not billed to insurance.

LASER HAIR REMOVAL for unwanted hair

The Candela GentleLASE PLUS laser is used to target and destroy unwanted hair follicles.  The wavelength of light specifically emitted by this laser is absorbed by melanin, the pigment in the skin and hair.  The laser light passes through the skin to be absorbed by pigmented hair in the hair follicle, where the laser energy is transformed into heat that specifically injures the hair follicle, and spares surrounding tissues.  Laser treatment is most effective on active, growing hair follicles.  Since hairs constantly cycle from active to dormant stages, multiple treatments are required to achieve best results.  It is expected that 4-8 treatments, at about 1-3 month intervals will be needed for significant, long-lasting hair reduction.  Because there is also melanin pigment in skin cells, the laser works best on persons with light skin and dark hair.  The laser does not work on grey hairs.  Persons with darker skin can still be treated, but may need more treatments at lower energies.

At your consult visit, we will discuss your skin type, predicted response to laser treatment, size of area to be treated, cost, and treatment schedule. Your medical history will be reviewed. You may be given prescriptions for medications, if necessary, including a topical anesthetic to use for the day of the procedure, if desired.  A laser test spot may be performed.  You will be asked not to wax or tweeze, or have electrolysis, for 4-6 weeks prior to the treatment appointment, (the hair root must be present in the follicle for the laser to work).  Shaving or clipping the hair is acceptable.  If you have darker skin, you may be asked to use a prescription bleaching cream for a few weeks prior to the laser treatment. Let your practitioner know if you have any tattoos or permanent makeup.

On the day of the treatment, you will be asked to mark the area of desired treatment, and then shave the area.  If desired, you will also put on the topical anesthetic. You should also remove any creams, perfumes, or makeup.  At the laser appointment, your eyes will be protected with special goggles. During the treatment, you will feel the laser handpiece touching the skin, then a cooling spray and almost simultaneous laser pulse, which feels like a rubber band snapping. Most all persons tolerate the treatment with minimal discomfort. Depending on the area to be treated, treatment time can take between 10 to 60 minutes. Immediately after the treatment, you may experience mild redness and swelling and itching, possibly feeling like sunburn, lasting a few hours.  There may be redness for 2-3 days. If there is scabbing or blistering, you should call the office, and may be asked to return for a post-operative check. After the treatment, some of the hairs will remain in the follicles, and may even appear darker then usual. They often will fall out within the next few weeks. Hairs that regrow are usually smaller, softer, and lighter. You should then return for repeat treatment, as scheduled. You can return to normal activities after the treatment, but we ask that you make your appointments at least 1 week before major social events. If desired, you can apply makeup when comfortable, usually several hours after treatment.  If necessary to remove hair after treatment, you should shave only for the 6 weeks after treatment, (and avoid waxing or tweezing).

Risks from laser hair removal are minimal, but can include the possibility of light or dark discoloration, blistering, bruising, or scarring. There is risk of eye injury, if the eyes are not shielded properly from laser light. The risks are greater on tanned skin; therefore, you should avoid tanning or sun exposure before and after the treatment. We also ask that you avoid artificial tanning creams before and after the treatment. If you have a history of Herpes virus infection (cold sore), you may be given an antiviral prescription to take, to prevent activation of Herpes infection by the laser treatment. Let your practitioner know about your medical conditions, such as warts, tendency to scar or keloid, or autoimmune diseases. Persons who have had the prescription medicine accutane within the past year should not be treated.

We hope you decide to proceed with this exciting new technology. It can provide you freedom from shaving, waxing, or tweezing, and the problems that accompany these hair removal techniques, such as razor bumps and cuts.
(www.candelalaser.com)

V-BEAM LASER

CANDELA V BEAM PERFECTA LASER for dilated blood vessels, rosacea, red birthmarks, sun damage, uneven discoloration, brown spots, scars, warts, and many other conditions

The Candela V Beam Laser is a pulsed dye laser, which delivers an intense burst of yellow light to the skin (wavelength 595 nm). This wavelength of light is absorbed by hemoglobin, which is in red blood cells. Because blood vessels are filled with red blood cells, laser light can be specifically absorbed in these areas, to diminish or fade the vessels, with minimal damage to surrounding tissue. The blood vessels are coagulated and reabsorbed by the body. The V Beam Laser has a unique cooling device, which sprays a cooling mist onto the skin with each laser pulse, protecting the epidermis (the top layer of the skin), and increasing comfort. In addition to hemoglobin, melanin, the pigment in the skin, absorbs the 595 nm wavelength of light. If lasering a pigmented brown spot on the skin is desired, a special handpiece is used. This handpiece compresses the blood away from the target area, leaving only the melanin to absorb the laser energy.

Many patients have small, dilated blood vessels on the face around the nose, cheeks, and chin. The cause of this is essentially unknown. Some patients may have a condition called Rosacea. Facial vessels and redness respond very well to the laser treatment. Small vessels on the chest and neck can also be treated. Benign blood vessel growths called angiomas can appear over the trunk, and look like small red dots. These can be treated with the laser. Red birthmarks also respond to the V Beam Laser. In general, dilated blood vessels on the legs (spider veins or varicose veins) do not respond as well to laser treatment. These are best treated by sclerotherapy (see separate information).  Lentigos are brown spots with increased melanin in the top layer of the skin. These often occur on the face, hands, and arms in response to the sun. Another condition caused by chronic sun exposure is “poikiloderma”, mottled brown and reddish uneven pigmentation, often on the neck and chest. Many patients also complain of uneven pigmentation on the face, from sun damage. These conditions can respond to the V Beam Laser. Optimal response may be achieved with several V Beam sessions, at one to two month intervals. (Moles are growths which contain mole (nevus) cells, and do not respond to the laser.)

At the laser appointment, your eyes will be protected with special goggles. The laser beam is aimed at the skin. You will feel multiple “zaps” which may feel like rubber band snaps. The mist may also be sprayed onto the skin. Most of our patients tolerate this without any problems. You can ask your practitioner about using a topical anesthetic before the treatment. Sometimes, cool compresses are applied after the treatment. Depending upon the number of areas affected, treatment time can take between 10-40 minutes. You may need several laser treatments for the best outcome. After treatment of red spots or blood vessels, you can expect post op changes ranging from minimal redness like a sunburn, or bruising (purpura), depending on the treatment selected by your practitioner. If you do not want excess bruising, your practitioner may purposefully select more gentle laser settings, and you may need more overall treatment sessions. Brown spots after treatment will usually turn red then dark after a few days, then peel away. The healing is generally a few days to 1-2 weeks. After treatment, you should not rub, scratch, or pick at the area. Avoid swimming, hot tubs, and contact sports if there is redness or irritation. If there is scabbing or discoloration, your usual moisturizer, makeups, and sunscreen can be used.

Risks from the V Beam Laser treatment are minimal, but can include the possibility of light or dark discoloration, or scarring. There is a risk of eye injury, if eyes are not shielded properly from the laser light. Some lesions will need more than one treatment, and may not be completely faded after the first visit. We recommend avoiding sun exposure before and after treatment. You will be asked to use sunscreen after the treatment. Self tanning products should be removed before treatment. Patients receiving Accutane treatment for acne should wait at least 6 months after completion, before laser. Tattoos should not be lasered. Let you practitioner know if you have a history of Herpes Simplex Virus (cold sores) in the target area, so that prophylactic treatment can be started before the laser. Topical medications should be stopped a few days before and after the appointment. Darkly pigmented skin may not be appropriate for laser treatment.

We are looking forward to treating you with this state of the art laser system. The V Beam Laser can be very effective at fading and diminishing redness and hyper pigmentation, with minimal downtime.
(www.candelalaser.com)

FRAXEL RE:PAIR LASER for skin resurfacing, rejuvenation, tightening, smoothing, and for scar improvement

Dermatologist Medical Group of North County now has the FRAXEL RE:PAIR, the third generation Fraxel (fractionated) laser that both rejuvenates the surface and tightens the deeper layers of the skin.  This laser makes many thousands of microscopic laser holes in the skin which repair (heal) themselves both from below and the sides. This results in more rapid and less painful healing than with deep chemical peels and unfractionated laser peels, where the entire surface of the skin is removed.  The expected surface improvements include a more even skin tone with reduction or elimination of dark areas and surface blood vessels. Recent work suggests it might even reduce the number of precancerous cells probably by stimulating the immune system as part of the healing process.  Because the laser energy goes deeper than in first and second generation Fraxel lasers, the Fraxel Re:pair also tightens the skin in addition to greatly improving fine lines and wrinkles. This can be thought of as a “mini face lift” without incisions. The Fraxel Re:pair may delay the need for a surgical face lift, and is a great procedure for patients who are not interested in surgery.  Acne and surgical scars can also be greatly improved with the Fraxel Re:pair laser.

For the laser treatment, you will be awake during the procedure, but will have pain control with oral medications, topical anesthesia, and injected anesthesia.  The laser has disposable tips with rollers that move over the areas to be treated under the guidance of the physician performing the procedure. Thousands of microscopic holes, as many as 22 per square millimeter (1/25 inch) are made in the skin, guided by the computer in the laser.  Your eyes will be protected during the laser treatment.  At the completion of the procedure your skin will be gently cleansed and an ointment will be placed over the treated area.  Expect swelling and some oozing, greatest for the first 24-48 hours, which will continue for 2-10 days depending on the area that was treated, the intensity of the treatment, and how fast you heal. Deeper treatment settings are needed for deeper lines such as those around the mouth, resulting in slower healing in these areas.  At your consultation appointment, you will be given pre-op instructions (such as premedication with antibiotics, antivirals, and/or bleaching creams, and discontinuation of blood-thinning medications), and post-op instructions (such as proper cleansing, wound care, and sun protection).

After the treatment and healing, you can expect your skin to be red for several weeks, longer if you have a tendency towards a ruddy complexion.  Dry areas and small blocked pores should improve over several weeks as well.  The skin should look smoother, blood vessels and discoloration should be greatly improved after the first 2 weeks. The tightening effect will gradually become more impressive as the deeper layers of the skin heal and remodel over several months. Do not expect to see this improvement any earlier than 6 weeks after the procedure. Further improvement can continue for up to 12 months after the treatment.  There is a chance you may have some hyperpigmentation after the treatment.  Studies have shown that fractionated lasers are much less likely to cause both lightening and darkening of skin, even in people with olive or darker complexions. This is because pigment cells next to the microscopic holes migrate within days to fill the holes.  The Fraxel Re:pair has much less down time than older laser and chemical peels, and is much less likely to cause pigment changes.

Because of the powerful Fraxel Re:pair technology, generally only a single treatment is needed for resurfacing and tightening.  Treatment of scars may take several treatments over the scar areas. 
(www.fraxel.com)

PHOTODYNAMIC THERAPY WITH LEVULON KERASTICK AND V BEAM PERFECTA LASER for photorejuvenation, acne, sebaceous skin (oil glands), and treatment of sun damage

Photodynamic therapy (PDT) is an exciting technology incorporating the application of a natural photosensitizing substance (Levulon, see below) to the skin, followed by activation with light. When the V BEAM PERFECTA laser is used to activate the levulon, the combination produces powerful results against sun damage, acne, and photoaging.
Changes in the skin from photoaging include pigmentation changes, brown spots, broken out blood vessels, redness, wrinkles, large pores, laxity of skin, and precancers. These changes can be treated with PDT. PDT can also be used in conjunction with standard acne treatments, for enhanced acne clearing. Some patients are not good candidates for standard acne therapies (or do not want to take oral medications). In these patients, PDT can be a great alternative to treat acne. PDT can improve some acne scars. PDT can also treat oil gland growths (sebaceous hyperplasia), minimize pores, improve skin texture, and decrease skin oiliness, by targeting oil glands.  Optimal PDT results are achieved with several treatment sessions, one to a few months apart.
Levulon Kerastick is a solution of 5-aminolevulinic acid (ALA), which is applied by your practitioner in our office. ALA is a substance which occurs naturally in the body. The Levulon is swabbed onto freshly cleaned skin, and allowed to absorb for 30 minutes to a few hours, while you wait in our office. During this time, the ALA is penetrating into the skin, specifically into areas of damage, precancers, and oil glands. You may feel slight burning. In the skin cells, the ALA is converted into protoporphyrin IX, which can be activated with light. When the incubation time is over, the area is treated with the V BEAM laser. The laser light activates the protoporphyrin IX, which then destroys the unwanted cells. During the laser portion of the treatment, your eyes will be protected with special goggles. You will feel multiple “zaps” which may feel like rubber band snaps. A cooling mist may also be sprayed onto the skin. There will be some burning. Most of our patients tolerate this without any problems. Depending upon the size of the target area, the laser treatment time can take between 10 to 40 minutes.
After the PDT session, you should expect redness, swelling, and peeling for 48 to 72 hours (like a sunburn). In some patients, this post-op redness is minimal. Other patients may experience more swelling, burning, some crusting, and tightness. If you do not experience redness after the first session, your practitioner will likely increase the strength of subsequent treatments, until you develop the post-op reaction. After the PDT session, it is important for you to protect from sunlight and bright indoor light exposure for 48 hours, since remaining light-sensitizing ALA will still be in your skin. You may feel burning with exposure to any type of light, during this post-op time. You will need to use titanium dioxide or zinc oxide based sunblocks, wear a hat and sunglasses, and stay indoors. Please bring a wide brimmed hat with you to your appointment, so you can wear it as you leave the office after the session. After the treatment, you can wash your skin with soap and water, and apply moisturizer. If there is a lot of crusting or blistering, you can apply Aquaphor ointment a few times a day. You can apply ice packs, and take Tylenol, aspirin, or Advil, if necessary. Makeup and topical medications (such as topical acne medications) can be resumed after crusting has healed. Applying makeup prior to this will not damage the treatment, but may just feel irritating. If you are having PDT to treat acne, your acne may initially flare after treatments. Brown spots in the treated area may initially become darker, before they peel off. Oil gland growths may be crusted after treatment. You should avoid the sun for two weeks, and use a sunscreen with SPF of 30 or more, for at least four months after treatment. Post-op redness will gradually subside over 4-8 weeks.
Risks from PDT with V beam laser are minimal, but can include the possibility of light or dark discoloration, or scarring. The redness after treatment may be prolonged, if there is exuberant response to treatment. There is risk of eye injury, if eyes are not shielded properly from the laser light. Self tanning products should be removed before treatment. Patients receiving Accutane treatment for acne should wait at least 6 months after completion, before treatment. Tattoos should not be lasered. Let your practitioner know if you have a history of Herpes Simplex virus (cold sores) in the target area, so that prophylactic treatment can be started before laser. Patients on blood thinning medications can develop more bruising from the treatment. Topical medications should be stopped a few days before and after the appointment. Darkly pigmented skin may not be appropriate for laser treatment. Pregnant women should wait to have PDT treatment. PDT may cause permanent hair removal, thus men should be cautious in treating beard and moustache areas. As with any cosmetic procedure, there is the possibility that you may not achieve your anticipated result.  We are looking forwards to treating you with this new and powerful combination photodynamic therapy and laser treatment.

REMOVAL OF UNWANTED TAGS, BENIGN KERATOSES, AND SEBACEOUS HYPERPLASIA

Skin tags are commonly found around the neck, and in areas of skin folds, such as the underarm area. They appear to be exactly as their name describes; loose little tags of skin. Seborrheic keratoses usually look like rough, brown growths on the skin, with a “stuck on” appearance. They can be located anywhere, and are commonly found on the face, back, limbs, or the area under the breasts. Sebaceous hyperplasia refers to a benign growth of oil glands. Usually these growths look like 1-2 millimeter yellowish bumps on the face.

Multiple different destructive methods can be used to remove these benign growths. Liquid nitrogen is commonly used to freeze off the lesions. Lesions can also be cauterized off, or snipped off. Your practitioner will determine the most effective method for you. After a removal session, usually the treated areas will have some swelling and crusts, lasting approximately one week. There is also usually some discoloration of the treated sites. You should avoid tanning for at least a few weeks before and after the session, to minimize the discoloration. Sometimes, lesions cannot be completely removed without extensive scarring, and may grow back. Often, patients will return for repeat sessions as new growths appear.

Although the actual removal of these growths is very simple, the most important task your practitioner must perform is to examine your skin, and determine which growths fall into the category of tags, benign keratoses, and oil glands. Most people have multiple growths on the skin, including moles and other benign or possibly cancerous tumors. Obviously, these latter lesions should only be removed by biopsy and pathology examination. Therefore, we suggest to first have a skin examination or consultation appointment, prior to scheduling a removal session.

Because skin tags, seborrheic keratoses, and sebaceous hyperplasia are benign growths, their removal is considered an elective cosmetic procedure.