So what 5 things to do?

1.  SUNSCREEN.  Not going to go on and on about this one.   You know it is good.  SPF 15 or 30.  Daily.  I don’t care if you aren’t outside a lot.  If you live in the Bay Area, you get tons of sun.  Sun is one of the most damaging, aging things you can do to your skin.  It will make you look old and wrinkly.  Block it.

2. DON”T SMOKE.  I won’t go on and on about this one either.  Smoking damages your skin.  It has toxins, it reduces blood flow, it causes little lines around your mouth.  The effect of it won’t show for years, but when it does it hits like a brick wall.  You can never fully reverse the damage smoking does.  So don’t do it.  It will make you look old and wrinkly.

3.  EXFOLIATE.  Cleaning your skin well is a must.  It will keep your skin healthier, remove all those bad things in the environment, reduce your pore size, and help your products work better by penetrating more.  You can use a chemical exfoliant (like my lovely glycolic acid pads!) or a mechanical one (like the clarisonic). 

4.  ANTIOXIDANTS.  These are products which help repair the damage to your skin.  Think of them as little doctors running around your skin fixing the injured cells.  Don’t buy over the counter products.  They are not the same strength and tend to cost as much.  Buy from a MD.

5.  VITAMIN A products, like Retin A and retinol.  This is still the gold standard for reversing damage in the skin.  I have tons of information on the subject.  If you don’t tolerate full strength Retin A, retinol is a good alternative.  Don’t do over the counter products- they don’t have the same strength medical grade products do.  Also, if you are within six months of trying to have a baby, you need to stop these products.  They are NOT safe during pregnancy and breast feeding.   

Dr. Zein Obagi started the line in Southern California years ago.  As this article in Plastic Surgery Practice states “For 25 years … he has written and rewritten the book on healthy skin.”  He does not judge skin based solely on the Fitzpatrick System (looking at white to black skin, and judging it on how it responds to UV light). 

He instead wants to base classification of skin based on a more “clinical classification” looking at five things:

• color
• thickness
• oiliness
• laxity
• fragility

He describes life stages of the skin: 

• Under age 10.  Properly clean and hydrate your skin.  Apply sunscreen.  He recommends antioxidants to prevent early damage from free radicals (**I am not sure how I feel about this.  I don’t know any research has been done on safety of antioxidants in young children.  Remember whatever you put on the skin can be absorbed through the skin. But I think it is an interesting concept and makes sense.)
• Age 10, the skin needs to be cleansed properly. If there are issues with sebum production (ie acne), you need to cleanse with a specific cleanser for oily skin and do a nonirritating scrub to prevent whitehead formation.  He recommends an astringent to decrease the sebum deep in the pores.  If needed, he also recommends hormone balancing.  The best you can do with acne scarring is to PREVENT it.
• After age 25:  He calls this the “inactive phase.”  Most cells making collagen and elastin become lazy.  This leads to aging.  So we should stimulate these cells.  The most effective agent to do this is Vitamin A- Retin A and retinol.  I agree with this statement.  Retin A products are well studied, their positive effects on the skin are well known, and it has been the workhorse of skin care for 20+ years.  I carry both Retin A and retinol in my office.  ***These products are NOT safe during pregnancy or breast feeding.  So if you are starting to think of babymaking, stop these 6 months before you start trying for your baby.

Other interesting pearls…

97% of the public gets skin care products from department stores and not physician offices.  This number surprised me.  The cost is usually similar (and for my personal line, my products are sometimes less).  Don’t pay for advertising and packaging.  Get a medical grade product.

Guidelines and safety in our industry:  He had an entire page dedicated to “unqualified doctors doing procedures.  We have board certified doctors who have worked hard in their training and worked hard to get the best results.  And we have a lot of other doctors who are not as well trained, who are doing it just for the money.  The dilemma is very big.  I think the future is not in creating more devices.  It is to create guidelines, to create standards. … I think the consumers really need to do their homework and go to board certified specialists and ask for a second opinion on a procedure.”  I agree. 

So at my favorite TIPS Plastic Surgery meeting in San Francisco in June we discussed many of the new things out there.  What I am repeating here is what I learned there. 

• platelet rich plasma.  Good stuff, may help fat survive, BUT you need a large amount of blood to get enough to help.  Likely not feasible.
• stem cells.  Studies showed if you supplement fat with stem cells you can increase survival.   Again a feasiblity issue- you need a lot of fat for a tiny plug of stem cells.  Many women seeking fat transfer don’t have much fat to transfer, much less extra liters of fat to spin down for a small plug of stem cells.

There is still a lot of controversy.  Yoshimura out of Tokyo has looked at stem cells a lot.  He focuses on the face.  He published a study in the Aesthetic Plastic Surgery Journal in 2008 showing adipose stem cell enriched fat showed increased transfer efficacy.  (IN NON DOCTOR TALK= When you move the fat, if you add stem cells to it, more of it lives.)  The ratio of stem cells to fat he used was high.  An issue remains – in order to get that amount of stem cells you need to harvest a lot of fat and distill it down to get the little tiny amount of stem cells.  Again, as I alluded to above, maybe stem cell enriched fat is better for smaller areas, where you are grafting less fat.  For large areas, it can be hard just to get enough fat to transfer, much less get extra liters of fat to spin down for stem cells to enrich the fat.  And many in the plastic surgery field say you don’t need to enrich the fat with stem cells, as fat is a rich source of stem cells in itself.  They argue when you transfer fat, you are transferring stem cells already in the fat.

And there are other basic questions about fat grafting which we don’t fully understand yet.  (This gets into more science-y stuff, so some of you may tune out)

• Do the cells you transfer live?  Or do the cells die and release something the neighboring cells like? 
• When he looked at the cells 4 weeks out, he found a lot of cells are dead, but there were new cells from the progenitor cells.  (It was like you tranferred a mommy cell which gave birth to new baby cells and then the mommy cell died.)
• At 3 months he found no more new fat.  At that point you could see oil cysts. (So things tend to stay stable after 3 months.  Until that point there is more flux with fat cells- some which have died are bdisappearing and the new cells which formed are growing)

From his research he hypothesizes during the first 3 months you see tissue repair, then for the next 9 months you see stabilization, oil absorbtion, or oil cyst formation.  Understanding what happens to the fat when we move it will help us be better at helping it survive in its new location.

All good stuff to help us make fat grafting techniques improve.

CURRENT SPECIAL: $50 off each vial, up to 3 vials.

My patients overall have loved it. The only issue I have heard of is bruising. To help stack the deck in your favor, please read my blogs on how to avoid bruising. Also ice your face on the way into the office.

I have loved the results- I think it is a beautiful, natural change. 

For how it works, follow this link. http://www.sculptraaesthetic.com/consumer/how-does-sculptra-aesthetic-work-video.aspx

Beware of doctors who are marketing, selling you hype, trying to bedazzle you with what seems like the newest greatest thing.  See my society’s position paper.  I think this is well stated.

What sources of stem cells are there?

• Embryonic- pluripotential stem cells.  Can form any cell in the body
• Fetal -amniotic, cord blood.  These are multipotential cells
• Adult- Bone marrow, fat

We know our body, even we old decrepit adults, regenerate.  Our skin regenerates and turns over every 3 weeks.  Our intestinal lining every 6 days.  Our bones, every 6 years.  So how can we harness this energy of turnover?  This talk at our recent meeting left more questions than answers.

Can we increase the number of stem cells?

Can we induce pluripotential cells?  They have started to do “reprogramming” of stem cells, to make stem cells pluripotential that otherwise would not be. 

The plastic surgeons interest has stemmed a great deal from our experience with fat and fat grafting.  (Who knew fat was such a valuable resource in the body?)  The hope is someday we could harvest fat, take out the stem cells, and program them to become liver cells, insulin producing cells, etc.  They have found there is some “memory” in the cells, so if you wanted to try to make skeletal bone, thigh fat is a better source than fat from other parts of the body.  Can we identify subpopulations of fat?  Is one better for blood vessels, another for bone, another for cartilage?

This research has been going on for a decade.  Don’t expect to be able to suck out some fat and grow new knee cartilage next week.  But that may be the direction we are heading.

I just went to the TIPS meeting in San Francisco- Technology innovation in plastic surgery.  One of the speakers talked about old buzzwords and the new up and coming ones.  I found it interesting, as I trained in the early days of “laser”- where everything would be better if a laser was involved.  Skin resurfacing by those old chemical peels or laser resurfacing.  A breast lift or a laser breast lift.  Eyelift or a laser eyelift.  Lasers sounded so cool, so hip, so NEW.  It must be better, right?  But when people used the laser, what laser? How was it used? What did it do to make the surgery procedure better?  There are hundreds of different lasers.  Just throwing around that word does not make for a better result.  Many of us found there was much more hype than real results.  And when you looked at the cost, risks, and little effect, are you better to do the NONlaser resurfacing?

So beware of the new sexy words.  In my blogs I will try to help demystify them.  There are absolutely exciting advances being made.  The new buzz on these advances is enticing for a reason.   But unfortunately unscrupulous marketers, media, and some doctors are putting the hype before the scientific proof it works, and many are using the words without actually doing it.

OLD BUZZWORDS:

• Flap and micro surgery
• laser
• ultrasound
• antiaging

CURRENT SEXY NEW WORDS

• Antiaging
• Stem cell.  (Stem cell facelift, stem cell fat grafting). 
• Growth factors.
• Ultrasonic, radiofrequency, photo
• Laser, fractionated laser

FUTURE BUZZ WORDS

• Regeneration
• Gene therapy and modulation

These are all real true advances in cosmetic and plastic surgery, but be wary of those who claim big gains.  With any product or claim, ask “Where is the science?”  Ask for scientific papers and proof before blindly signing up.  The speaker highlighted one of the products.  His quote, which I loved, I will repeat:

“If you have to show the effect of the product on EM (electronic microscopy) and not a typical H&E histology stain, then you are likely not going to see a clinical effect.”  In English what this says is if you have to blow it up a gazillion times under a microscope to see what it is doing, and can’t see it under a normal histologic slide, then it isn’t doing anything you, the patient who does not have eyes which focus as well as a microscope, will see.

• cell enriched fat
• “growth factors” (not defined)
• stem cells
• fat alone
• fat enriched with extra stem cells

He then did a medical literature review of 9000 references.  What did he find? Only 20 articles discussed stem cells with fat grafting, and most dealt with fat grafting to the breast.  Only three articles discussed the face, one of which was a case report.

Hmmm.

How can a doctor declare “Stem cell facelift!” and state it returns your skin to its prior youthfulness and plumpness when there are no scientific papers to back it up?  And what is this stem cell? Is it the naturally occuring stem cells in fat and this is really just fat grafting like so many other plastic surgeons do?  Are they adding stem cells to the fat (like they do with machines where you harvest a liter of fat and spin it down to get a tiny plug of stem cells?)

ASAPS and ASPS released a joint statement stating the results of stem cells are promising, but not proven.  Any claims a doctor makes on what it can do cannot be scientifically supported yet. 

They likely do hold promise in the future.  All of us who have done fat grafting to the face have seen impressive changes.  They are subtle, over time, but clearly there.  I had a patient who had bad acne scarring of the cheek.  We did fat grafting to her cheek and a year later noticed the acne pitting was softer, the skin quality better.  Dr. Coleman in New York has a great slide of a woman’s nose where he fat grafted it and years later when she returned a big scar on the top of her nose had miraculously disappeared.  There are stem cells naturally occuring in fat- in fact many think fat is one of the best sources of adult stem cells in the body. 

We are at the beginning of understanding stem cells and what they may mean.  I am proud of our society for approaching these new advancements with thoughtfulness.  They want to maintain integrity, trust, honesty.  In order for us to make claims of the miracles of stem cells, we need evidence based medicine.  We need to do good studies to evaluate what it is and what is happening. 

Beware of the doctors who are better marketers than honest doctors.  As our speaker said, on the “stem cell facelift” webpage, in fine print at the bottom it says, “No claims are made these procedures are proved by FDA or effective.”

TIPS-technology innovation in plastic surgery- meeting was anything but mundane. It was interdisciplinary with researchers, companies, doctors. Plenty of Q&A time. Topics which are salient to now. I am proud to be a board certified plastic surgeon. I am proud of those who organized the meeting and those who attended. As a group they truly seem focused on real science, good medicine, and the future.
Blogs will follow, many of which reach much farther than what most would think of as the realm of plastic surgery. We plastic surgeons are doctors of the skin and wounds. In the past amazing advances have been made with flaps and grafts. Now heralds a new era. Topics:

• Biofilm.  Have you even heard of this? It is critical in healing of open wounds, any implants (from hip replacements to breast implants), and a likely culprit in capsular contracture.
• Noninvasive liposuction
• Skin resurfacing.  radiofrequency, ultrasound. 
• Fat grafting. To the breast and other areas.
• Stem cells. In fat and other areas.
• Tissue engineering.  Acellular dermal matrix: mesh now for hernias and breast reconstruction, but in the future scaffolds to create anything?
• Scars scars scars. Insights and some promising new future treatments?

It was a great meeting.  I highly recommend to to all plastic surgeons.  psurgtips

Technically, photoaging is damage and aging to your skin caused by the UVA and UVB rays in sunlight. Chronic exposure to sunlight (which we definitely have here in the Bay Area) causes UV damage in the skin.  The ultraviolet light alters our skin cells at a genetic level, causing free radicals and DNA damage. 

Most people think of sun damage as just pigmentation, sunburns, or cancers.  We need to think of youthful skin as being healthy skin.  A lot of what I see when people come in with complaints of “aging” are due to sun damage.  What are signs?

• broken blood vessels
• wrinkles
• roughness on the skin
• actinic keratosis (little patches of rough areas. These are a sign of pre skin cancer)
• pigmentation
• redness
• skin cancers (melanoma, basal cell, squamous cells)

The skin cancer foundation has a new ad campaign which I like.  It says “Go with your own glow.”  They have catchy ad campaigns like “Keep tanning. You look great in leather.”  Or “Tanning’s fifteen minutes are over. Let your inner health, beauty, and vitality shine through.”

I am going to do a series on skin health.  Not only does it prevent skin cancers, it makes you look better too.

www.skincancer.org