Room for Improvement

No matter what the specifics are regarding any particular cosmetic procedure, the goal is the same: enhanced appearance. There are so many options out there because one patient’s problem areas aren’t the same as another’s. For some, it may be those pesky frown lines; for others, it’s the turkey neck that suddenly appeared at age 50. Leg veins, brown spots, uneven skin texture … the list is expansive. Fortunately, so is the practitioner’s toolbox.

the neck

For species other than the clunky bird it’s named after, the turkey neck is not a desirable trait. Loose, flabby neck skin can make us less satisfied with our appearance, but there are solutions. Promise.

the telltale signs
Saggy, wrinkly necks are a major aspect of cosmetic surgery and dermatology, says Dr. Richard W. Maack, an otolaryngological and facial plastic surgeon at Synergi Facial Surgery in Chesterfield. “People come in all day and say, ‘I can’t stand my neck! All this skin is hanging down!’ The surgical face-lift is the gold standard, but a lot of people may not need that yet or do not want to have surgery. We can do some neat stuff for them that is not as good as surgery, but the results are just short of it.”

“We know a neck that looks old versus a neck that looks young,” says Dr. Joseph A. Muccini, a surgical dermatologist at MidAmerica Skin Health & Vitality Center in Chesterfield. “There are a couple of things that contribute to what people don’t like about their necks,” he says. “A lot of it is genetic. In some younger patients, we see a bit of bulkiness. Some people will have a double chin, and some lack profile definition. A person can be thin and still have bagginess in the neck due to the collection of fat. The other component is loose skin.”

gravity is not our friend—again
The hanging skin results from years of tissue aging and gravity, Maack explains. “The collagen loosens; it is like an elastic band that stretches. It loosens outside of the muscle, so even if you say you are going to tighten your neck with exercise, it doesn’t do anything.”

Injectable deoxycholic acid, under the brand name Kybella, has been approved by the U.S. Food and Drug Administration to reduce fat under the chin. “It disrupts the fat cells and causes them to die,” Muccini says, usually after several treatments.

Tissue freezing and liposuction also reduce fat tissue in the neck, he says, but his favorite tool is the PrecisionTx laser. “It is minimally invasive with three tiny holes. You insert a laser that will literally melt fat by passing the fiber optic wand under the skin.” The heat produced under the skin also tightens skin, he notes. “The PrecisionTx can tighten the skin, reduce fat volume, or do both. People will continue to tighten for six months after the treatment. It is not intended to require more than one treatment.”

“One of the neatest things out there is a combo procedure called microneedling with radiofrequency,” Maack says. “A little pad has 40 needles that go very quickly in and out of the skin. Radiofrequency comes out of the needles while they are under the skin. The heat from the radiofrequency waves is directed where the fibrous collagen tissue is. The collagen is irritated and tightens as it heals. We usually do an area three times; a deep pass gives deep tightening and a superficial pass gets the fine lines. It is typical to do up to three treatments about a month apart.”

Each microneedling/radiofrequency procedure costs about $900, he says. “There is a definite, visible improvement. The effects are not as long lasting as with a face-lift, but it is a longer-term treatment,” Maack explains. “People might want to come back in a year or two to do it again.”

An ultrasound procedure, Ultherapy, “is very popular and works well for neck tightening,” he adds. “The device delivers two ultrasound waves that come together under the skin. There is a deep thermal response where they meet that heats the tissue. As the body heals, that tissue tightens.”

While the physicians are excited about these nonsurgical options, they repeat that nothing matches the results of an actual face-lift. “We don’t want to mislead people,” Maack says. “People who have hanging skin are going to see much better improvement with a face/neck lift.”

combination procedures

Many medical issues are the result of more than one cause, hence they are labeled ‘multifactorial.’ Their treatments, too, require more than one approach to get optimal results. And like a combo meal at the drive-thru window, combination treatments can cost you less for a better outcome.

new filler pairs well
Carol Anderson, a certified aesthetic nurse specialist and owner of Nouveau MedSpa in Kirkwood, says, “There may be a variety of ways that you arrived at the problems you have and a variety of ways we can address them.” Science has circled back to autologous adipose tissue (the patient’s own fat cells) for more satisfactory and lingering effects. This modality is autologous lipocyte micronized injection, or ALMI.

ALMI can be combined with light or laser skin surface treatments for added improvement to skin texture and tone, says Dr. Richard Moore, cosmetic surgeon and medical director of The Lifestyle Center in Ladue. “ALMI is a natural substance obtained from the patient’s own body,” he explains. “It is combined with a little bit of platelet-rich plasma from the patient’s blood and injected in a similar way as a dermal filler. One benefit is the longevity of the treatment. And we have unlimited volume and improvement in the texture and tone of the skin.”

an obvious improvement
Older fat cell transfers, developed decades ago, were a great idea since they used the patient’s own living tissues as a dermal filler. However, Moore says, “The biggest issue with fat transfers to the face historically has been that they were very unpredictable,” he says. But ALMI utilizes just the cells that create new fat cells. “We harvest a small syringe of fat and process it to remove the mature fat cells. That leaves behind the regenerative cells—things like stem cells,” Moore notes.

For a typical procedure, Moore removes about 20cc of fat, usually from the patient’s lower abdomen. After processing, the remaining cells total about the same amount as 15 syringes of dermal filler.

cost-benefit analysis
“After it is injected, it re-establishes the collagen and supportive matrix of the skin,” Moore says. “There is a smoothing of the skin, a decrease in wrinkles, and volumizing—all at the same time. It can be put in places that are difficult to use fillers, like under the eyes in the hollow tear troughs and underneath the eyebrows.”

The treatment takes about an hour. “We expect a much longer-lasting result than we would get with a dermal filler, something along the lines of two to five years. It’s also less expensive,” Moore says. “For a full face, the cost (of ALMI) would be around $3,500, almost half of what one year of filler treatment would be.”

another effective combo
A popular combination at Nouveau MedSpa removes brown spots, stimulates collagen growth under the skin and rehydrates the face, Anderson says. “This is a popular combo because it makes a dramatic change in a short period of time. We do a light Forever Young BBL (broadband light) treatment and, the same day, a light microneedling with PRP (platelet-rich plasma). The PRP helps with healing and filling the tiny, fine lines in the skin,” she says.

“We follow that five days later with a hydrating facial. In one week, you eliminate some brown spots and sun damage, start new cell turnover and rehydrate everything. You have a clearer, more even-toned and smoother complexion.”

Scheduling the treatments as a package saves time and money, she notes. “If you did all those things separately, it would be about $1,000, but as a combo, the price is about $850. We like to look at your face and design a personal treatment plan, combining several modalities that help you reach your goal.”

If your doctor says you have remarkable telangiectasias, he isn’t complimenting your flower garden. He’s telling you the spider veins on your legs are showing. Those may be only cosmetic, but for some people, the little blue wisps progress to unsightly varicose veins. And those may warrant a medical examination to rule out deeper, troublesome venous problems.

common culprits
The great saphenous vein is the longest vein in the body, extending from the top of the foot to the upper thigh and groin. Closer to the surface of the leg is the small saphenous vein. “The legs are supposed to be a low-pressure system when the valves are working in sequence up and down the legs, but when the valves are broken, there is very high pressure,” explains Dr. Norman N. Bein of Vein Specialties.

“Blood from the legs returns to the heart through the saphenous veins,” adds Dr. Robert Fischer, a radiologist at SSM Health DePaul and St. Clare hospitals. “Over time, in some patients, the valves in the small saphenous veins become leaky. Blood that is supposed to travel in one direction, to the heart, refluxes back into the legs. That can lead to the problems we see with varicose veins and spider veins.”

The problems are not merely cosmetic and can lead to swelling, skin color changes and eczema, Fisher says. “The end stage of the disease is an ulcer, and those are very difficult to treat.”

teensie, weensie spiders 
Spider veins may occur in 80 percent of men and 85 percent of women as they age, according to medical journals. Many fewer, about 23 percent of U.S. adults, are afflicted with varicose veins, those dark purple or blue streaks visible and sometimes bulging through the skin.

Heredity is the key root of these venous issues, Bein explains. “They are seen more in women because their veins dilate during pregnancy due to the increased blood volume for the baby.”

Spider veins are treated as a cosmetic issue. “Sclerotherapy is internationally the gold standard,” says Maria Bein, R.N. and clinical director of Vein Specialties. The small veins can be treated in two to five treatments, she adds. The treatment consists of injecting a chemical solution that causes the veins to collapse and eventually disappear. Nearby veins supply the blood flow to adjacent tissues.

a progressive problem 
“Many people come in for sclerotherapy, but I perform an ultrasound to make sure there is nothing going on under the surface,” Bein says.

Fischer adds, “The classification is a step-wise process. The first step would be reflux without anything visible. Then we see the small spider veins, and from there, varicose veins and swelling.” Most patients want to take care of the unsightly issue for cosmetic reasons. “But if we don’t treat underlying problems, those can progress to swelling, skin changes and ulcers. Everyone who has varicose veins should seek medical attention and at least get an ultrasound to check the severity of reflux.”

Conservative measures for varicose veins may be prescribed first, often because insurance companies require it, Fischer continues. “Compression stockings are something we recommend,” she says. “I typically suggest patients try to exercise daily (although there is no evidence to support the idea that exercise changes anything).”

Years ago bulging veins were commonly treated with vein stripping, Fischer notes, but his practice likes a minimally invasive treatment called endovenous laser therapy. “We insert a small laser in the vein and as we withdraw it, we apply heat to close the vein,” he describes. Bein notes that deeper issues with varicose veins are almost always considered a medical issue and are covered by insurance.

Endovenous laser therapy costs may range from several hundred to a few thousand dollars, depending on the amount of veins requiring treatment.


Room for Improvement
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Room for Improvement
No matter what the specifics are regarding any particular cosmetic procedure, the goal is the same: enhanced appearance. There are so many options out there because one patient’s problem areas aren’t the same as another’s. For some, it may be those pesky frown lines; for others, it’s the turkey neck that suddenly appeared at age 50. Leg veins, brown spots, uneven skin texture ... the list is expansive. Fortunately, so is the practitioner’s toolbox.
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