Skin Care - Frequently Asked Questions (FAQ)

Q. How safe is Botox?
A. Botox Cosmetic has been used for at least 17 years now and is considered an exceptionally safe drug whose uses are extending past just cosmetic, to treat migraines, excessive sweating (hyperhidrosis) and even intraopratively where muscle relaxation is desired. There were over 3 million doses of Botox Cosmetic in the U.S alone this past year with few serious problems. Most of the disturbing information you hear about ie., the internet, is with a different more powerful form of Botox used to treat muscle overactivity in children with cerebral palsy or other neurological illnesses. In this group, death can occur, however, this is well known and accetable risk for these kids with severe extremity muscle spasm. This is NOT Botox Cosmetic which has been extensively studied and has a very high saftey profile. That having been said, there are small risks to everything we choose to do in our lives, and you should make an informed decision with your doctor.

Q. How can I get better hair removal results?
A. IPL is certainly not the best equipment for laser hair removal, although it is OK for some people. I prefer Cutera technology which uses the very fast and effective Prowave 770 on lighter skin patients or the 1064 yag on darker skin types. We get superb results in both groups! The FDA definition of permanent hair reduction is 85% or more. Sometimes, additional sessions are required after the first 5 or 6, and we offer those at no additional charge in our office. Go to Cutera.com for additional information about their lasers, and good luck.

Q. Can I get Botox if I'm a heavy pot smoker?
A. Botox Cosmetic is terrific for skin wrinkles. Pot smoking is probably making them worse. You can do both, but it's kind of like playing one against the other. Smoking, of any kind, is just bad for the skin and accelerates the appearance of aging. There are pictures of Twins where one smoked and the other did not...the results are frightening. One can understand occasional MJ use, but heavy smoking is worse for your lungs than smoking cigarettes.

Q. Should there be wrinkles after Botox?
A. Relax...5 days is way too soon to fully evaluate results. Often, once the Botox works well to smooth the crows feet, people begin to notice other areas that were not their primary concern. Maybe it's worse, but maybe it looks worse in contrast to the smoother lateral eye area. If the possible swelling does not improve, 1-2 units of Botox placed just below the eyelashes works to reduce this crepiness. Be sure your Cosmetic Surgeon is very experienced to treat this area.

Q. Does the number of injections have anything to do with Botox results?
A. No. It is not the number of injections that determines results with Botox, but the number of units placed, the locations, and the skill of the injector. Aestheticians should not be doing Botox injections in my opinion. Leave it to well qualified doctors or RN injectionists. The quality of Botox injections received in a "day spa" , and the end result, are unlikely to match those received in a physician's office. Botox is not a "Costco" product. Choose more cautiously and wisely next time, so you get excellent results that we have all come to expect with Botox.

Q. Does Botox cause birth defects?
A. As a Lifetime Ob/Gyn Fellow, I am often asked this question. Botox has an incredibly high safety record, but NO competent physician would use it in pregnancy. If there was a problem with a newborn, the guilt of the possible cause and effect of Botox would be enormous for you, in addition to the serious ramifications for the injector. Enjoy your pregnancy. It's a wonderful time in your life full of many legitimate concerns and risks. Certainly another is not needed ...so avoid Botox during prenancy and lactation! Very early pregnancy seems to be pretty well protected from most external medications, so termination would not necessary.

Q. Botox cost - CC's vs. units?
A. Most physicians charge Botox by the unit (100 units per bottle) ... or by the area. Being charged by the unit is of course the most accurate because you know exactly what you are getting and "exactly" what you are paying for it. It is normal to have the injector tell you how many units are planned before it goes. Then it's simple math. Pricing by area gives you less certainty about how many units you are getting from your injector and therefore makes it a bit less certain what you are actually paying, i.e. did the $300 for the glabella use 15 units or 25? Pricing by CC has the greatest potential for ripoff, as you are paying for the diluting solution to mix the Botox. The cost per unit can be increased dramatically by volume without the patient knowing how much Botox really was administered. As a plastic surgeon friend used to say "you don't need to be a Neurosurgeon to give Botox." You just need good training, experience, and, of course, ethics.

Q. Paying for Botox by the vial?
A. You need to have a frank conversation with your injector. Did he use a full vial of Botox Cosmetic? Was it a 100 unit vial or one of the newer 50 unit vials? In either case 50 or 100 units is too much for crows lines alone. Why did the amount change so much from your previous injections? Unless you are mistaken about the facts, or he has a reasonable explanation, you should consider changing injectors.

Q. Will Botox injections before Fraxel Repair produce better results?
A. Nearly all Cosmetic procedures that are non-surgical work best when combined. Each procedure tends to do something a little different... and we often talk about the concept that 1+1 equals 3. Botox relaxes overactive muscles allowing any resurfacing to appear to provide better and smoother skin results. This is because the resurfacing is not fighting with the muscles.
I agree with others that Botox 2-3 weeks before any type of resurfacing is a valuable adjunct and will enhance the overall results.

Q. Is it safe to have Restylane and Botox on the same day, and while on antibiotics?
A. It is very common to do both Botox and Filler injections on the same day. I would not recommend doing Botox in the glabella and Juvederm there at the same time. Do one first and wait a week or longer to do the second treatment in the same area. I agree with Dr.Freund that elective cosmetic treatments should not be done during an active infection. Wait until your tonsilitis is resolved.

Q. Can Botox raise the nose tip?
A. It depends on anatomy and the injectionist's experience.
You might also consider a filler like Restalyne or Radiesse. We are having great success treating nasal irregularities with filler, whether at the bridge of the nose, crooked appearance, or tips. In fact, Dr. Stephen Mulholland a well known plastic surgeon in Toronto promotes and succeeds with what he calls the "5 minute nose job." It works! Please choose an injector with a lot of experience.

Q. Can Botox injections keep me mentally and physically young?
A. Botox Cosmetic cannot make you physically fitter with the exception of migraine reduction, improvement of hyperhidrosis, or treatment of some ocular issues. There certainly have been many studies showing improvement of "self" esteem and depression with many cosmetic treatments including Botox. We are all living longer, hopefully eating better, and taking care of ourselves with increased exercise. It is disheartening to many people to feel good on the inside and see an older looking person staring back from the mirror each day. In our "appearance oriented" society looking better improves self esteem, affects how others regard you, and is often valuable in job hunting. While you may disagree with this, a yogi treated recently in my Boulder practice described it this way: "Even though I believe in reincarnation and other spiritual and energy forms, I will most likely be on this earth in this "form" for the next 50 or so years so I might as well make my external appearance as comfortable as I desire." I agree.

Q. Botox for sweating - How long do the effects last?
A. Hyperhidrosis or excessive sweating usually require 100 units of botox for the axilla and less for the hands. The procedure is FDA approved. In my practice, the average duration seems to be about 6 months. For people with this significant issue, Botox provides good relief and high satisfaction. Good luck.

Q. Can Titan work for my skin if Active FX did not?
A. Different Lasers seem to work better for some than for others. It is impossible to know in advance what the end result will be. I am sorry you did not get the results you desired with the Active FX. In my office we use Titan combined with Laser Genesis (both Cutera) around the eyes to lift brows and tighten skin. We get some very nice results this way with no discomfort at all. I would suggest you get a consultation with an office experienced in this combination approach. Of course, ask to see their Before and Afters. Good luck!

Q. Which is better for tightening the thighs and buttocks, ReFirme or Titan?
A. TITAN is the preferable treatment for skin tightening in the face, neck and body areas for patients who do NOT want surgery. There is no downtime at all. We have had very good results in the abdomen post pregnancy, and our pre and post photos are available in our office. It is very comfortable compared to radiofrequency ( I have had both myself) and has a good patient satisfaction rate. My favorite approach for skin tightening, in the neck, thighs, and abdomen is the new MPX Smart Lipo device. The skin is heated in subdermal grids to 38-40 degrees Centigrade with careful temperature monitorning. The stimulation of collagen is quite profound and the results are excellent. Be sure to choose a physician who is very experienced with this device as it's new to the market. I usually recommend a doctor who has performed 100 cases or more. Good luck!

Q. Titan for upper arms?
A. I like TITAN for skin tightening on the body very much. I also feel that it does as good a job on the face in "lifting" as well as any external device, ie. Infrared or Radio frequency. However, it is not a miracle treatment and one needs to have realistic expectations. If it is just loose skin that you hope to tighten, then TITAN may indeed help. If there is loose tissue as well, it is likely fat, and the MPX Smart Lipo would be your best choice by far. It melts and removes fat, and the internal skin tightening is superior to other methods. Talk to your physican directly and discuss these issues. Also be aware that the tightening is due to collagen stimulation with TITAN and the final results are best appreciated 3-4 weeks after the last (generally 3rd) treatment.

Q. Can Hyaluronidase injections dissolve Juvederm several months later?
A. If there is still juvederm present, the hyaluronidase will probably dissolve it and help.If the swelling or bag is actually due to fat herniation, then you probably need a surgical treatment ie., blepharoplasty. Try the hyaluronidase. It works quickly. If no improvement I would suggest a consult with a plastic surgeon. Good luck!

Q. Brown discoloration from Juvederm?
A. It could be some bruising after the injection has left pigment changes that have discolored. I have had one patient with a similar issue and it improved with a combination of Laser Genesis (Cutera) with a little IPL below the eyes, but not 100%. This is not a common problem. I'm glad you tried the hyaluronidase and got some relief. Consider gentle laser treatments. Good luck.

Q. What is the average cost of Juvederm per unit?
A. Juvederm is sold by the syringe, not by the unit as Botox is sold. There are 2 types made by Allergan: Juvederm Ultra, and the slightly heavier Juvederm Ultra Plus. Typically one buys a syringe or two which are used on the same day, however some product can be refrigerated and saved for up to 6 months. Cost varies by geographic area as well as the experience and skill of your injectionist. Avoid low price offers, as this is not a "Costco" item. The range can be between $350 to $625 per syringe, and the results are immediate. It's ok to shop price, but remember cheapest is often not best. Choose an experienced injectionist.

Q. Is Juvederm only sold by two vials?
A. Juvederm comes 2 syringes in a box, but are sold often one at a time. You should speak to your doctor, as they should only use what you request.

Q. How long does Juvederm typically last?
A. Juvederm is an FDA approved hyaluronic acid. It is approved to last up to 1 year. In my experience, it seems to last about 8 months the first time one uses it, but if you repeat it before it's completely gone, it will often last up to a year. It is soft and very natural in appearance and has a high patient satisfaction rate. Areas with more movement ie. the lips tend to last less (5-6 months) than areas on the face that have less muscular movement (6-12months). The skill of the injector definitely affects longevity.

Q. Laser hair removal treatment for PCOS patient?
A. As a Lifetime Fellow of The American College of Ob/Gyn, I know how difficult this problem can be. I would suggest 2 approaches. First, you should be on treatment from your doctor for the PCOS. If you are not, then doing LHR will be frustrating as it will keep recurring. Treatment ranges from birth contol pills to more advanced medical therapies and might even require surgery. Once the PCOS is under control, I would suggest considering a different laser for the hair removal. Longer wavelenths like the 1064 yag are effective and safe for darker skinned patients. I like Cutera's LHR technology, but there are several others as well. Finally, you are not putting yourself at any known risk with the laser hair removal treatments. Good luck!

Q. Which is better between Fraxel Repair and Pearl Laser?
A. I find that the best indication for Fraxel is to repair acne scarring, because it can go deeper if that's required (usually NOT necessary for most patients). It requires several sessions with about 4 days of downtime. I like the Pearl laser very much because it provides new skin with just 3-4 days of social downtime and is a great texturing laser with collagen remodelling that occurs for several months after. Also, it generally requires just 1 treatment. Both are good technologies, but I prefer Pearl, unless your acne scarring is quite bad.

Q. Fraxel Repair vs Pearl Laser for acne scars?
A. Both Pearl and Fraxel give good results for scarring. I recommend Pearl for superficial scarring and Fraxel CO2 for deep scarring. The new Pearl fractional provides significant improvement. The advantage of Pearl is less discomfort and faster recovery and the need to do it only once or twice. The CO2 laser builds more collagen deeply, but generally requires more treatments with a somewhat longer recovery. Again, I would decide based on depth and extent of scarring and your goals. Have an evauation by experienced physicians offering both. Good luck.

Q. What should laser hair removal cost?
A. I like Cutera technology for Laser Hair Removal. We get great results in all skin types with 5-6 treatments with the spacing determined by the area. We charge $600-800 for a bikini (not Brazilian which is more) or the same for underarms. Full legs in a female is $1750 to $2250. Pricing range depends on specials that run periodically for different areas. Note that prices will also vary in different areas of the country. If you find an offer for considerably less than this, be cautious, as the laser they use is probably less effective. Often we re-treat patients from these mini-spas who are unhappy with their results, and they have to purchase an entire new package. So trying to save money can prove more expensive in the end. Choose based on the technology (google and educate yourself)...and an office's reputation. Good luck.

Q. Laser hair removal for redheads?
A. Sorry, but laser hair removal does not work well for red hair. The laser needs to see the brown or black pigment in the follicle to work. We have had some limited results with Meladyne to darken the follicle, but only in the 50% effective range. Consider electrolysis or be patient... as new technologies come out every month.

Q. Best laser treatment for broken capillaries and brown spots?
A. I agree with the previous 2 answers. I prefer Pearl for brown pigment in one treatment. It has a very high patient satisfaction rate (90%). Laser Genesis works extremely well for reds and is very gentle. Any remaing tiny vessels can be easily treated with a vascular tip hyfercator.
Cutera's IPL with a programable wavelenth works well on both brown and reds. There are many alternatives. The key is finding an experienced laser doctor in your area who can evaluate you and make appropriate suggestions. Pick a center with multiple lasers or you will simply get the one they happen to own. Good luck!

Q: Laser resurfacing and microdermabrasion for acne scars?
A: I agree that microdermabrasion and superficial lasering will do nothing for ice pick scars. Deeper lasering may help, but they do have significant downtime. We have had good results is some patients filling these scars with Juvederm or another type of filler. Though the scar is still present it can be more easily and effectively covered with concealer. We just treated a young woman with significant scarring prior to her wedding, and although not perfect, she was very grateful for her results, and how she looked in her wedding photo album.

Q. Can laser resurfacing and wrinkle fillers be combined?
A. Recent studies in the past 2 years have shown the lasers may actually improve the longevity of H.A. fillers. We used to be concerned that the heat from the laser might hurt the integrity of these fillers, but fortunately the opposite appears true. The fillers are placed deeper than most lasers go so no need to worry, but of course it's wise to ask your doctor which laser he is using. I would not recommend doing both procedures on the same day as the pain level increases significantly. I usually do them a week or two apart.

Q. How long do Pearl Laser results last?
A. Sun damage and how well you care for your skin post procedure certainly affects results. The end result seems to depend on how much collagen is stimulated by the treatment ,and this is age related with younger patient's results (35-55) lasting longer than older patients (50-65). *I think that an estimate of 5 years with Fraxel is overly generous and unrealistic. It certainly has not been seen in my office. I love to ski and am in the mountains regularly. I wear a light cotton mask on my face even in warm weather. I may not look too cool, but my skin holds up great. Also Solumbra sun protective SPF clothing can be very helpful.

Q. Treatment for irritation after Pearl Laser?
A. Yes what you describe is a very common appearance 3 days post Pearl Resurfacing. It should peel and resolve in the next several days. If you have excessive itching, you should contact your doctor to make sure you don't have a contact dermatitis which needs to be treated with steroids, but that sounds unlikely. The honeycomb appearance will disappear when you peel in the next day or two.The red spots will gradually subside. Keep it moist with Aquafor or Silkses by Sesderma. Follow up with a call to your doctor. You should do fine and will love the results in a week or so.

Q. Pearl laser - Is this treatment effective?
A. We have been using the PEARL lasser for over a year now (FDA approved 5/07) and are very pleased with the results.To date, we have done over 100 patients. It is comfortable with only BLT numbing cream and takes about 20 minutes to perform. It provides brand new epidermal skin with just 3-4 days of social downtime, while providing heat to the deep dermis resulting in significant texture improvement over the next 4-6 months. One treatment will remove 60-80% of brown pigment, and we are now able to use it on most Fitzpatrick 4 skin types. It can be used to treat the eyelids to the lash margins and can be used on necks, chests, and hands. If you have redness, I would suggest combining it with Laser Genesis. Overall, it has been a very nice addition to our cosmetic practice and I can recommend it without reservation.

Q. Skin tightening devices that are safe and don't cause fat loss?
A. I have used TITAN by Cutera for 4 years now. I have never seen a patient with fat loss secondary with this procedure. Pearl as well does not cause fat loss as the very long erbium wavelength does not get near the subcutaneous tissue. I have seen fat loss in the cheeks with RF (Thermage) and unfortunately I myself had this problem. I have resolved it well with Sculptra injections. I also found the procedure more painful than the Titan. CO 2 Fraxel also is useful for skin tightening, but I like TITAN for its comfort and its no downtime aspects. Pearl has a 3-4 day social downtime, but only requires one treatment.

Q. Help with uneven lip augmentation?
A. Wait a couple or three weeks for it to even out. If you are not happy, you can either consider using more filler to even it out, or use hyaluronidase to quickly dissolve it and return you to your pre-injection state. Always choose a very experienced injectionist when doing lip augmentations as they can be tricky. Relax, it should work out fine. Good luck.

Q. After three laser facials, I still see fine lines around my mouth?
A. Laser facials help with fine lines, but unless you are doing a deep resurfacing, it won't help much with deep peri-oral and upper lip wrinkles. Botox works well for many patients in the upper lip to smooth lines, and with 8-12 units is the least expensive approach there. Juvederm or Restalyne works well to lift the corners of the mouth, and I prefer Sculprtra in the nearby cheek folds as it lasts18 months to 2 years. If I were to use a laser here to help, I would choose the fractional Pearl which does work on deeper lines.

Q. Laser hair removal for folliculitis?
A. Laser hair removal for folliculitis is very helpful to many. Think - no more shaving, waxing, or tweezing, which aggravates this skin irritation. It is particularly good in African-American males, who often suffer with this issue extensively, and can be a life altering procedure for many. Find an experienced office with appropriate technology for your skin type. Remember your hair needs to be brown or black. Reds, Gray, and Blond are not effectively treated by laser and may be approached wih electrolysis. Good luck.

Q. Laser hair removal safe around areola?
A. Nipple area hair can be removed from the areola using a yag 1064 laser. The hair color needs to be black or brown color. The laser will not see blond, red, or gray hairs. These can easily be removed by electrolysis. Go slowly, as this is obviously a more tender area to treat in most people.

Q. Laser hair removal after chin implant?
A. If your chin implant has healed properly, laser hair removal should be fine. The hair follicle target is in the dermis, well above the depth of your implant. However as a safety precaution I would ask your plastic surgeon for clearance beforehand. Good luck with both!

Q. Can Hyaluronidase injections dissolve Juvederm several months later?
A. If there is still Juvederm present, the hyaluronidase will probably dissolve it and help. If the swelling or bag is actually due to fat herniation, then you probably need a surgical treatment ie., blepharoplasty. Try the hyaluronidase. It works quickly. If no improvement I would suggest a consult with a plastic surgeon. Good luck!

Q. Best alternative to laser hair removal for dark skin?
A. Laser hair removal can be done very carefully and safely in darker skinned people. We do it all the time. We have great succes with Cutera's Cool Glide which was created for this issue. It make take a few more treatments than with lighter skin, but the results are worth it. Good luck.

Q. Facial rejuvenation treatment with long-lasting results?
A. I would suggest you consider the PEARL laser by Cutera. In addition to one of the fastest recovery of the lasers you mentioned, the Pearl removes the majority of brown pigment with one treatment. There is normally just 3 or 4 days of sociaI downtime with minimal procedure discomfort. It simultaneously sends heat to the deep dermis providing collagen stimulation and smoothing of the skin over the next few months. We have been getting excellent results with a very high customer satisfaction rate. Cost is $1400-1750 depending on where you live. Good luck.

Q. Length of time between laser hair treatments?
A. In our office, 4 weeks seems to work well for underarms and female bikini. Leg treatments are usually done at 6-8 week intervals, and male back for at 8 weeks. The timing can be moved up or slowed down by the hair growth returning sooner or later. Generally 6 treatments are required to meet the FDA definition of permant hair reduction.

Q. Is laser hair removal safe for pregnant women?
A. As an Ob/Gyn I would definitely agree the answer is NO.Though unlikely to affect fetal growth and development ( laser hair removal is a superficial treatment) why put yourself in the position of taking any risk in pregnancy! It is an elective treatment so YOU can choose the proper timing. In addition, pregnancy stimulates hair growth in unexpected places, so it's better to let the pregancy hormones subside after delivery to see what remains and what areas need treatment. You may be surprised ... I do not offer laser hair removal during gestation, though I would not be alarmed if one had a treatment prior to knowing she was pregant.

Q. What laser companies won't survive the recession?
A. Cynosure continues to bring strong new technology to the market place. The sales of their Smart Lipo and MPX upgrade continue to be excellent. They recently released their new Fractional CO2 device which is outstanding. If you want real information however, get the financials from the companies themselves...and then be "completely skeptical" and go to any of the financial sites on the internet and plug in the company name. Not only will you get detailed information about how the financial analysts see THAT company, but you'll get comparisons with all the others in the industry. MSNBC.com has great business tools to do this yourself, or ask your broker. Best to make a wise well-informed decision.