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Inland Valley Daily Bulletin Smooth Operation By La Rue Novick Most people have what they consider "problem areas" on their bodies. For some it's the nose. For others it's love handles. For Judy Kroeger, Vielka Abad and Sharon Griffin, it's wrinkles. Instead of worrying and feeling self-conscious, they did something about it. They got Restylane injections from Dr. Jeffrey Rebish, a dermatologist in Upland. "My husband said, "You're getting younger by the day,' " Kroeger, a part-time resident of Glendora who spends summers in Ohio, said about a month after receiving Restylane injections in a couple of creases between her eyebrows. "I look a lot different." Restylane, a transparent, biodegradable non-animal filler, first became available in Europe in 1996. In December, the federal Food and Drug Administration determined that Restylane is safe and approved its use for filling moderate to severe wrinkles around the nose and mouth, according to a press release issued by the FDA. There are two other injectable products approved by the FDA for treating wrinkles, collagen and botulinum toxin (Botox). Collagen is a dermal filler and Botox softens wrinkles by relaxing the muscles in the injected area. Some dermatologists say Restylane is better than collagen, even though the FDA determined that the manufacturing company, Medicis Aesthetics, failed to prove Restylane's superiority. Other physician say it just has some added benefits, such as lasting longer than collagen, but is no better than collagen. "The advantages are the results last longer, it's not an animal product and it's different, more liquidy, which makes it look nice," said Dr. Jacob Haiavy, a cosmetic surgeon practicing in Upland. "I think it's an excellent filler." Abad thinks it's an excellent filler too. She had Restylane injections more than a month ago. About three weeks after the treatment that filled in the smile lines from her nose to upper lip, also called nasolabial folds, she said she believed it made a huge difference. "My face looks natural," the 47-year-old Anaheim resident said. "For my age it looks real nice." She would definitely do the injections again, she added. By now, dermatologists and plastic surgeons nationwide should have access to Restylane. Rebish was one of the first in the Inland Valley to make the product available to his clients after it was approved. Haiavy said his shipment should be here by midmonth. On Jan. 22, Kroeger awaited her Restylane injections in a small, sterile room at Rebish's office. Rebish leaned in close to Kroeger, whose forehead had been numbed with numbing cream, and slipped a tiny needle into portions of a deep crease located near her left eyebrow. (Restylane is injected about 2 to 3 millimeters beneath the surface of the skin in tiny amounts with a very fine needle.) Kroeger had already undergone a Botox treatment in the area between her eyebrows, to paralyze the muscles and keep her eyebrows from knitting. But she had a couple of stubborn creases that didn't go away with the Botox treatment. So she decided to have it filled in with Restylane. "Botox and Restylane work very differently. The Botox probably helped her not frown anymore and it maybe softened the wrinkle, but there's still a wrinkle there," Rebish said. "So we're going to combine both treatments to erase the crease." Rebish slowly injected the clear gel into each spot, pulled the needle out and dabbed at little speckles of blood forming from the pinpricks. He tapped on each area to smooth out the substance and worked his way down the crease. "Maybe it will make me smarter," Kroeger, 63, said jokingly after responding that the process didn't hurt "too bad." One of the differences between collagen and Restylane is that collagen has an anesthetic already in it. Restylane does not. And numbing cream doesn't always work that well, Haiavy said. "Because Restylane doesn't have the anesthetic in it, it's a little more painful for the patient," Haiavy said. Kroeger later said that the pain, though not terrible, made her reconsider getting the injections again. "I don't know if I'd go through that again," she said. "For younger women or men, it wouldn't be a big deal." During her procedure, Kroeger's wrinkles visibly filled in, though not all the way. "After a week, I looked good," Kroeger said about a month after her injections. Immediately after the 30-minute procedure, Kroeger's forehead between her eyebrows looked a bit puffy and splotchy red. Rebish explained that about 12 percent of Restylane clients have swelling and redness for a few days, especially in the lip area, where Restylane is typically used. Restylane is most popular for lip augmentation and for treating the nasolabial folds, he added. "As we age our lips gets smaller, so a lot of people like to emphasize their lips," Rebish said. In addition to erasing her deep smile lines, Griffin, 56, wanted to emphasize her upper lip. "I didn't want big ol' Goldy Hawn lips" (as in the movie "First Wives Club'), the Chino resident said. "I just wanted it to match my lower lip." After the procedure that took place nearly two months ago, she said she liked her lip a lot better and that her nasolabial folds were nice and smooth. "I didn't realize how much I needed it until (Rebish) did it," she said. "I did it for me. It was something that made me feel better. What's most important is what I see in the mirror, not what other people think." Griffin said she tried collagen, which has been around for more than 20 years, for the first time in 1988. She tried it again in 2000. She was happy to learn that Restylane not only lasts about six to nine months -- collagen lasts about three -- but that it's made from a complex sugar, hyaluronic acid, and is not an animal or human protein. Hyaluronic acid naturally occurs in living cells and is found in abundant quantities in all human soft tissue. It fills the space between collagen and elastin fibers. It's safe and almost never causes allergic reactions, Rebish said. Bovine collagen, which comes from a cow, can cause allergic reactions in about 3 percent of the population, Rebish said. An allergic reaction would make the person look red or swollen in the injected area and the area would probably itch for about three to four months, Rebish said. For this reason, bovine collagen requires a skin sensitivity test prior to the treatment. Restylane, because it is sugar-based, does not. According to Inamed Aesthetics, the company that markets the human collagen products CosmoDerm and CosmoPlast, human collagen replacement doesn't require a skin test either. An added benefit of Restylane is it seems to go further than collagen, Rebish said. "It would take less volume of Restylane to achieve the same amount of correction as collagen," he said. Restylane is a lot less lumpy and tends to be smoother than collagen, he added. So why would anyone choose collagen? Perhaps because it is cheaper than Restylane, which costs $475 for one syringe at Rebish's office and $550 at Haiavy's office. Zyderm and Zyplast are two types of bovine collagen that have been on the market for 23 years. The range in price for these products at Rebish's and Haiavy's offices is $350 to $400. CosmoDerm and CosmoPlast have been on the market six months and cost between $400 and $450 at Rebish's office and $475 at Haiavy's. "Restylane is more expensive but lasts longer," Rebish said. "I think Restylane will replace collagen on the market." There is another hyaluronic acid filler not yet approved by the FDA and that's Hylaform. Where Restylane is man-made from bacterial fermentation in a lab, Hylaform is derived from roosters' combs, according to Dan Cohen, vice president of global government affairs for Inamed Corp., the company marketing Hylaform. Cohen said Inamed Corp. will market Hylaform to work hand-in-hand with collagen because together they can provide much better filling power. Plus, with collagen's added anesthetic, the Hylaform injections won't hurt as much. Hylaform, co-marketed by Genzyme Corp., is already used in Europe, Canada, Australia and other countries and is currently under review by the FDA. Cohen said Inamed Corp. anticipates approval within the month. According to a Reuters article published in the November issue of Forbes Magazine, "Restylane is the market leader in the more than 60 countries where both products (Restylane and Hylaform) are now sold." Getting the wrinkles out Botulinum Toxin Type A, according to the federal Food and Drug Administration, is a protein complex produced by the same bacterium that causes food poisoning. It was first approved by the FDA in 1989 to treat eye muscle disorders. By April 2002, it was approved to treat frown lines. The effects last up to four months. Botox temporarily relaxes facial muscles and prevents a person from being able to move them. Botox has become increasingly popular with more than 1.6 million people receiving injections in 2001, according to the American Society for Aesthetic Plastic Surgery. Botox is mostly used in the upper face. The only FDA approved places of use is the glabella (the area between the eyebrows). Other common areas where it is used are the forehead and crow's feet. HUMAN COLLAGEN: CosmoPlast and CosmoDerm, human collagen is derived from human skin cells in a laboratory. These products, which contain the anesthetic lidocain, became available about six months ago following FDA approval. They are used to correct soft tissue defects such as wrinkles and acne scars, according to the FDA. Some studies show human collagen to last up to six months. Human collagen does not require a skin test like bovine collagen. BOVINE COLLAGEN: Bovine collagen has been around for more than 20 years. Zyderm and Zyplast were approved in 1981 to fill unsightly facial wrinkles. Doctors have used it to fatten lips too. Bovine collagen also contains an anesthetic, so it is less painful when injected. The results last up to three months. Maybe more. Bovine collagen continues to be a popular filler but because it is animal-based, a skin test is required prior to the procedure, Rebish said. RESTYLANE: Restylane is a colorless, biodegradable, sugar-based filler approved by the FDA in December. It contains no anesthetic and can be painful when injected. It lasts longer than collagen, about six to nine months. Restylane is made up of hyaluronic acid, a naturally occurring substance in all living cells. It is manufactured in a lab and is derived from bacterial fermentation. Restylane is approved by the FDA for treating the areas of the mouth and smile lines from nose to upper lip.Trouble spotsMelasma -- dark pigmentation of the skin -- has several apparent causes and avenues of treatment By La Rue Novick
Brown spots might look cute on cows, but not on someone's face. A growing number of women today are noticing dark splotches collecting on their cheeks, foreheads and upper lips. Too much sun exposure can cause sun spots. But melasma, a patchy or generalized dark pigmentation of the skin, is a bit more complicated. There is research that points the finger at hormonal changes due to pregnancy and use of contraceptives. Less proven is melasma's connection to hormone replacement therapy and menopause. Heredity and certain anti-seizure medications can be factors, some say. But a third of time it happens in women, and even men, for no known reason. "Melasma is most commonly seen on Asian and Latino women," said Dr. Jeffrey Rebish, a dermatologist with a practice in Upland, "but it can be seen on anybody." The American Academy of Dermatology recently reported that melasma affects 5 million to 6 million people nationwide. Five to 10 percent of these cases are males. For many women, the dark discoloration is embarrassing and they're willing to do almost anything to get rid of it. Marica Blades, 46, of Upland fits in that category. "You don't want to have these kinds of things on your face," she said, "especially when you're in your 40s. ... I want to look good." Blades went to Rebish nine months ago to get help with the unsightly dark spots on her cheeks. She had tried over-the-counter bleaching creams, but they didn't work. When Rebish prescribed another bleaching cream, she was skeptical, she said. Over-the-counter creams usually contain about 2 percent hydroquinone, an active bleaching ingredient, but prescription creams contain 4 percent and sometimes higher, Rebish explained. (The cream doesn't actually "bleach" the skin, but instead decreases the activity of the dark-pigment-producing cells.) Blades began using her prescribed cream and found it was working. Rebish suggested a series of Jessner's peels, a type of chemical peel, in combination with the twice-daily regimen of bleaching cream. After her sixth peel, usually done once a month, Blades said she has seen a considerable difference. "It's so much better. The texture of my skin is so nice and the spots are very light," Blades said. Treating melasma takes patience and diligence. Results won't appear overnight. Some melasma cases are more severe, the discoloration running several layers deep. Those people will get results from treatment, but the spots may never fully go away, Rebish said. SOME SOLUTIONS *Apply an SPF 30 broad-spectrum sunscreen daily to protect against UVA and UVB rays. "The most important part of treatment is no sun exposure," Rebish said. Someone who has made great progress with treatments could ruin it all in one day by spending time in the sun without protection, Rebish said. Wear a hat, stay in the shade and most of all, don't forget that sunscreen. Pregnancy-induced melasma (referred to as the mask of pregnancy) will often fade away several months after the baby is born, Rebish said, but birth-control-related melasma tends to be much more persistent. "If they stop the birth control pills and stay out of the sun, it could fade away over several years, especially if they're trying to treat it, but it also might be quite resistant to treatment," Rebish explained. Mild cases of melasma caused by birth control can be treated if the woman would rather not stop taking the pill, said Dr. Gloria Stevens, a dermatologist practicing in Upland and a clinical associate professor of dermatology at USC. "But if you ask me ideally? Ideally, you should come off it," Stevens said. *Use special topical agents such as bleaching creams with hydroquinone. Prescription creams are stronger, generally better and cost about $65 to $95 for a two-month supply, Rebish said. They can be combined with use of retina-A or glycolic acid for added effectiveness, Stevens said. But they must be used as directed. "They (people with melasma) have to be very good about doing it," Stevens said. "It's not something you do here and there, it's very regimented." It takes at least two months of using bleaching creams to see results, she added. Those using a compounded bleaching cream with a higher concentration of hydroquinone, such as 8 percent, run the risk of darkening the skin even more. Over-use of a prescription topical agent containing a steroid could cause stretch marks, increased blood vessels and thinning of the skin, Rebish warned. "You can use it for a short period of time, but you should switch it after three to six months," Rebish said. Another topical treatment used with some success is azelaic acid, a naturally occurring acid found in grain, Stevens said. *Get a chemical peel. In addition to bleaching creams, dermatologists may recommend a series of chemical peels. Rebish said chemical peels are great for treating superficial melasma. Chemical peels that use trichloroacetic acid, glycolic acid or salicylic acid cause the top layer of the skin to shed, often revealing more even-colored skin, according to an AAD article on melasma. Chemical peels are usually done once a month for five to eight months, depending on the severity of the melasma. Chemical peels cost about $80 or more for each session. *Try laser therapy. Photorejuvenation, done with an Intense Pulsed Light laser, is more effective when treating acne scars and sun spots, but it has been successful in treating melasma in some cases. Asians, African-Americans and Latinos should be cautious of laser therapy because the minor trauma to the face could cause more darkening of the skin, Rebish said. Laser 'facial' can lighten dark patches Angel Bustamante, 34, of Fontana was walking by the laser center, located between Dave & Busters and Rain Forest Cafe, and was tempted to go inside. She'd had brown spots on her face for some time and wanted to know what she could do to get rid of them. Bonnie Schmidt, a registered nurse and head nurse trainer for Nuvo International, suggested Bustamante do a series of FotoFacials featuring IPL therapy. Bustamante agreed to do one session. First, Schmidt applied numbing cream to the client's face and let it sit for 30 minutes. She explained that not all clients want to use the numbing cream, but it is available. "As a spa setting, we want people to be as comfortable as possible," Schmidt said. One zap of the laser, without numbing cream, isn't unbearable by any means, but some people are more sensitive than others. After Schmidt zig-zagged clear gel (which acts as a conducting agent for the laser beams) over Bustamante's face and spread it out evenly, she began zapping the areas of discoloration using a handheld device that delivers the laser's energy through a crystal plate, roughly the size of a stick of gum. "The laser sees pink or brown on the skin and it is attracted to the darker pigment," Schmidt explained. After a series of bright flashes followed by a cooling treatment, the FotoFacial was done. There is no redness or peeling associated with this treatment, hence "the lunch-time facial." Schmidt wiped the gel off, cleansed the client's face and coated it with a strong sunscreen. "We won't let people leave here without sunblock," she said. "If she were to go out in the sun without protection, she'd be like a magnet (to the sun's rays)." At the end, Bustamante simply said, "That was wonderful." She hadn't decided if she'd be back again. Schmidt said for the photorejuvenation to be effective, Bustamante would need a series of five treatments. Because each FotoFacial session is $495 at Nuvo, it is better to purchase a package that combines five FotoFacials with five microdermabrasions (mild sanding of the skin surface) for a total of 10 procedures in five months at $1,699, said Susan Gelnette, a company spokeswoman. Photorejuvenation works 25 percent better if the skin is prepped with a microdermabrasion treatment at least a week prior, Schmidt said. Photorejuvenation isn't for everyone. Darker skinned individuals have to be careful because the lasers are automatically attracted to darker pigment, said Dr. Christopher Pederson, Nuvo's corporate medical director. |
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