The major stereotypes of the male cosmetic medical patient have been the aging, narcissistic homosexual actor and the young, narcissistic homosexual bodybuilder. Now there is a new stereotype and label for a man who cares about his appearance but does not want to be labeled gay—the metrosexual. In fact, there are plenty of males who seek cosmetic interventions who do not fit into any of these categories.

Men have the same basic concerns about appearance that women do, and there are cultures past and present where male adornment is as important if not more so than female adornment. Still, the aging process has always been more socially acceptable in men than in women. Aging tends to emphasize a man’s masculine features and tends to garner him more respect. Older men, especially successful men, have less trouble finding romantic partners than do older women. Having said that, men (and women) value fi rm, muscular, well-proportioned physiques for men. Features such as waistline fat, saggy eyelids, and too little or too much hair on certain body parts are not favored.

As we have seen, standards of personal appearance are culturally determined and perpetuated by media and marketing. In our culture, at least until recently, men have not been much targeted by the fashion, beauty, and cosmetic medical industries. In modern times, with increasingly sedentary jobs and rising obesity rates, fewer and fewer men are candidates for statuary modeling. This shifting of the typical American male body away from the Apollonian ideal has led to a series of fitness crazes and the birth of a subculture, the Bodybuilder. Beginning with Eugene Sandow, billed as “The World’s Most Perfectly Developed Man,” and followed by Tarzan, Charles Atlas, the Mr. Universe contestants, and other familiar contemporary icons turned politicians, bulked-up men have achieved a certain level of status in our society. The antithesis—the fl abby couch potato—is a person almost certain to be discriminated against socially and in the workplace. Thus liposuction has earned its place beside dusty treadmills and unused health club memberships on the to-do list of many American men. The cosmetic medical care industry has added to its mantras a new oxymoron: “Pampering Tarzan.” According to the ASPS, about 1.2 million cosmetic procedures were performed on men in 2005, less than 15 percent of the total cosmetic procedure volume. As a group, men are more inclined toward procedures with little or no downtime, no swelling or other evidence of treatment, and stripped-down skin-care instructions. Therefore, men lean toward the minimally invasive procedures and are also said to be the fastest growing segment of consumers of cosmeceuticals. Nose surgery is the cosmetic operation most frequently chosen by men. Following rhinoplasty and vying for a distant second place, the invasive cosmetic procedures men most commonly seek are hair transplantation, liposuction, and eyelid surgery. The fifth most common operation is gynecomastia surgery (male breast reduction). The volume of fringe procedures like penis lengthening, despite a certain amount of lurid press, is probably overinflated. No one knows for sure.

In the men’s noninvasive category, Botox rules, followed by microdermabrasion, laser hair removal, chemical peels, and filler injections.

MALE RHINOPLASTY

Of the nearly 300,000 cosmetic operations on men reported for 2005, about 35 percent were nose reshapings; still, far fewer men than women undergo rhinoplasty. Many cosmetic surgeons feel that rhinoplasty, despite its popularity, has signifi cant psychological risks associated with it for adult men, whereas teenage boys usually adjust well. In fact, some experienced cosmetic surgeons feel that the adult male rhinoplasty patient is the most difficult category of cosmetic patient. A reduction rhinoplasty, in which the nose is made smaller, seems particularly prone to creating dissatisfaction. As an interesting corollary, there is some evidence that homosexual men seeking rhinoplasty to feminize their features are more likely to be satisfi ed with the results.

MALE FACELIFT, EYELID LIFT, AND BROW LIFT

Men do have facelifts, but the numbers are relatively small. Often they cite professional reasons or the desire to impress a younger lover. Facelifts on a man can be more challenging surgically than is the same operation on a woman. Physiologically, male facial skin differs from female facial skin; it is thicker and has increased blood supply. The hair is of different quality, and hair distribution must be considered not only for the sake of appearance but for the mechanics of shaving. After a facelift some men can be left with an inconvenient change in their facial hair growth pattern, especially in the ear region, and some patients may even need to consider laser hair removal or electrolysis as treatment for undesirably relocated hair. The robust blood supply of a man’s facial skin leads to a higher risk of blood collection (hematoma) after surgery, which can lead to skin loss or long- term skin pigment changes. It is difficult to hide the evidence of a facelift on a man; unless he wears makeup or long hair, his barber and other close observers will likely notice the scars. Men also have eyelid and brow lifts, often to improve their fi eld of vision. Eyelid lifts are similar to those performed on women. Brow lifts on men usually present the dilemma of where to put the incisions, and the resulting scars may be visible. A man with a receding hairline may be horrified to wake up one day and discover that his scalp scar is suddenly on his forehead. Facelifts, eyelid lifts, and brow lifts are discussed in other posts.

HAIR TRANSPLANTATION

All surgical forms of hair replacement involve transplanting a patient’s own hair from one portion of the scalp to another. For men with large bald areas, operations called flap procedures may be necessary. Tissue expansion is another option, in which balloons are positioned under thick hair-bearing areas of scalp and infl ated slowly to stretch the scalp. Later, portions of the bald scalp are removed and the stretched hair-bearing sections pulled over the excised bald areas. These kinds of operations require general anesthesia. Tissue expansion creates a significant, although temporary, deformity of the head shape and as a result may not be feasible for many men. For a man whose baldness is confined to a limited spot on the crown of the head, it may be possible simply to excise the bald area during a series of operations, often under local anesthesia. This surgical technique is called scalp reduction.

Less extensive baldness is commonly treated with hair transplants and has evolved from the visible plug transplants to what is called microtransplantation, in which tiny grafts of one to three hair follicles are moved from thick growth areas on the sides or back of the head to thinned areas in front or on top of the head. Microtransplants are performed with local anesthesia, with or without sedation, in an office setting. Because the procedure is tedious, multiple sessions over many months or years may be required. Some physicians specialize in hair transplantation and have developed an extremely streamlined, labor-intensive pro cess in which up to several thousand grafts can be transplanted per “megasession.” Successful hair transplants tend to be stable and long lasting; even though microtransplanted hairs fall out shortly after surgery, most will regrow. The best candidates for hair transplantation are patients with thick, healthy hair growth along the sides and back of the scalp, the prime donor areas. Patients with extreme baldness and very little donor hair are much less likely to have a natural looking result, no matter what procedure is performed, and most prospective patients in this category should be discouraged from undergoing surgical hair transplantation.

Complications of hair transplantation procedures are low. Major flap operations have higher risks, scarring may be visible, and additional procedures are often necessary. After microtransplantation some hairs will not survive, requiring additional sessions to achieve the desired effect. The characteristics of a transplanted hair may not be the same as the original hair, and original hairs in a balding area may continue to thin out over time.

The bottom line: Hair transplant techniques have improved dramatically, but in order to get a good result, most patients still need to submit to multiple tedious procedures over a long time period at signifi cant expense.

BODY CONTOURING FOR MEN: LIPOSUCTION AND IMPLANTS

Men seek body-contouring cosmetic surgery for several reasons. Some want to reduce “middle-age spread,” some desire to rid themselves of excess skin after major weight loss, and others are involved in self-sculpture. For the first group liposuction and skin excisions are often prescribed (see Chapter Eight). For the last group, liposuction has been used to sculpt belly fat to simulate the bulging muscles of a “six-pack” abdomen, and synthetic implants may be used to enhance the contours of pectoral muscles, arms, legs, and buttocks. Synthetic implants inserted to augment muscle contours are prone to several complications, also discussed in other posts.

MALE BREAST REDUCTION

Some men have distressingly prominent tissue in the breast area. Breast enlargement in men is called gynecomastia and can be due to breast gland enlargement or obesity. Men can also develop gynecomastia as a result of using drugs such as marijuana and anabolic steroids. A man with gynecomastia that is severe or fails to resolve after adolescence should have an evaluation by an endocrinologist (a physician who expertise includes conditions caused by hormone abnormalities). In rare cases, male breast enlargement can be caused by breast cancer.

Gynecomastia can be treated surgically with excision, liposuction, or a combination of techniques. The surgery requires general anesthesia and possibly an overnight stay in the facility. Drains may be left in place for several days, and the patient must wear a tight, vestlike compression garment for weeks. Pain can be significant for the first forty-eight hours. Risks include permanent contour irregularities and noticeable scars, especially if significant amounts of skin have to be removed. Gynecomastia in teenagers is discussed in other posts.

OUTCOMES FOR MEN

Many cosmetic surgeons note that male patients do not listen or communicate as well as female patients, and as patients men can be more challenging than women. Their compliance with instructions tends to be less than ideal. As a group, men also recover from surgery differently than do women. Men have lower pain thresholds and more difficulty curbing their activity level during the recommended recovery period. Nonetheless, with the possible exception of adult male rhinoplasty patients, men overall tend to have outcomes as good as those of women. However, in order to facilitate their convalescence, prospective male cosmetic patients should make a conscious effort to be informed about what to expect postoperatively.

The acids most commonly used for peels are (in approximate order of intensity) alpha hydroxy acids (AHA) such as glycolic acid, lactic acid, and fruit acids; beta hydroxyl acids; vitamin A (tretinoin); trichloroacetic acid (TCA); and phenol. All acids can be used diluted or full strength, depending on the patient’s skin type and the goals of treatment.

Before undergoing certain types of chemical peeling, patients may be required to pretreat their skin at home with a topical medication like Retin-A. Lighter chemical peels (AHA peels) are performed in an office setting without anesthesia. The chemical solution is painted on the skin, and the patient may experience a mild burning sensation and slight, temporary redness. Patients can resume normal activities immediately, as long as they use sun protection. TCA peels may cause a more intense reaction, especially in higher concentrations, and the patient will have some activity restrictions for a few days.

Deep (phenol) peels are generally reserved for more severely wrinkled and sun-damaged skin and are not for the fainthearted. Phenol is an especially powerful and potentially dangerous chemical and is toxic to the heart if excessively absorbed. Phenol peels should only be performed by an experienced, qualified physician in a controlled environment in which the patient has cardiac monitoring by appropriate personnel. Phenol creates a significant burn. After a phenol peel the patient may experience severe swelling and may have to avoid talking and solid foods for several days. The crust that forms after a phenol peel must be kept soft with ointments and may take several days or weeks to come off entirely. Complete healing may take as long as a month, and patients may have their activities significantly curtailed during that time. Phenol peels are rarely performed these days. Incredibly, some states allow nonphysicians to administer any type of peel, including full-strength phenol peels. Common side effects of chemical peeling are visual skin pore enlargement and blotchy pigmentation after sun exposure. Patients are strongly encouraged to use high SPF sunscreen after any type of peeling. After a phenol peel some degree of permanent skin bleaching is virtually guaranteed, and blotchy pigment irregularities may persist, especially if isolated sections of the face were treated. Infection and scarring are potential complications after chemical peels, especially medium and deep peels.

The bottom line: Chemical peels can help improve the appearance of the skin of properly selected patients. The milder peels are safer, even though multiple sessions may be necessary for a good result. Deep wrinkling requires a deeper peel, but the risks are significant. Because the results of chemical peeling are so operator dependent, the stronger chemicals are highly likely to lead to complications when improperly used. Because peels may be offered in salons and medical spas, a patient should be very careful when selecting a provider for a chemical peel.

Dermabrasion and Microdermabrasion

Dermabrasion has been used by cosmetic surgeons for decades to help smooth irregular skin surfaces, especially those affected by burns and acne. These mechanical methods of skin resurfacing can be alternatives for patients who are not candidates for chemical peels. The tool used for traditional dermabrasion resembles a small drill with a sanding bit or wire brush. Dermaplaning is a similar procedure in which the skin is shaved rather than sanded. Many physicians feel that traditional dermabrasion is overrated. It can yield some improvement of surface irregularities but almost never to the degree that the patient wants. Dermabrasion has been largely replaced by laser resurfacing, although it still has a role in treating acne scars.

Modern technology has provided a method of “dermabrasion lite” called microdermabrasion. This technology, widely available in salons, uses tiny crystals to sandblast the surface of the skin, knocking off the dead cells and leaving the skin with an appearance very much like that of a good facial. Microdermabrasion of your face is like buffing your car: You look great afterward, but the effect is short-lived.

Laser Resurfacing and Photorejuvenation

Photorejuvenation is one of the newest entries on the list of words that have been invented to describe new technological applications. It refers to light-based treatments designed to improve the appearance of the skin. There are two types of light technology, lasers and intensed pulsed light (IPL) sources. Lasers emit tremendously magnified light in a single or narrow band wavelength, and different lasers do different things to skin. Intense pulsed light (IPL) is also magnified light but uses a much broader portion of the spectrum. IPL is promoted for many of the same indications as are lasers. IPL is also used to treat sun damage and skin cancers as part of a process called photodynamic therapy. Magnified light sources are frequently used in the treatment of both cosmetic and medical skin conditions. Photorejuvenation technology has been further classified into two categories according to the goals of treatment. Some machines are designed to treat skin discoloration; others are engineered to target skin structures in an effort to improve skin texture. Very broadly, this translates to mean that various light sources are used to treat brown spots, red spots, and wrinkles. Every laser or light source has its advantages and disadvantages—things it does well and things it does poorly.

Laser and light treatments are considered ablative or nonablative, depending on how much damage the skin sustains during treatment. Ablative treatments are those causing significant burns that require long healing times; these carry more risks, yet generally yield better and longer lasting results. Most ablative lasers can be “dialed down” to nonablative settings, but results are less impressive.

Ablative laser resurfacing can be performed with numerous lasers, including a specialized carbon dioxide (CO2) laser, an erbium: YAG laser, and several new lasers such as the Fraxel. The fi rst surge of interest in laser resurfacing occurred a decade ago when the specialized CO2 lasers came on the market. However, it soon became evident that high doses of laser energy were required for good effect and that those high energy levels were yielding a significant rate of complications such as permanent skin pigment alterations and scarring. Even so, some surgeons prefer ablative lasers for treating wrinkles around the mouth and eyelids.

Fraxel is the proprietary name of a laser manufactured by Reliant Technologies that uses a mechanism of action dubbed fractional photothermolysis. The advantage of this partic ular laser technology is reported to be its ability to treat many of the manifestations of photoaging, including wrinkles, fine lines, and pigment irregularities, better than nonablative laser treatments but without the prolonged healing time of ablative treatments. To date very few studies on the effectiveness of fractional photothermolysis technology have been completed, so although the concept is promising, the value of this type of laser is too early to call. So far it appears that multiple treatments at significant cost will be required for visible effect. If this laser proves successful, we can look forward to a fl urry of “fractionating” and “fractional” technologies that may or may not have equivalent benefits.

Recovery after ablative laser resurfacing can be quite prolonged, much like that after a phenol peel. Depending on the technique used, skin healing may take weeks, during which time the patient may experience significant pain and swelling. The skin will remain red for weeks, pink for even longer. Some physicians cover the treated skin with dressings for much of the healing phase; others require the patient to apply thick layers of ointment regularly. The pendulum swings back and forth between chemical peels and laser treatments as the preferred method of skin rejuvenation. An individual provider’s recommendation will be driven by his or her experience, comfort level, and available technology.

The bottom line: The usefulness of laser rejuvenation/resurfacing depends mainly on the willingness of the patient to accept the significant downtime and risks that accompany ablative treatments. Lesser procedures have significantly lower cost/benefit ratios.

Radio Wave Treatments

Several radio frequency devices (Thermage, Thermacool, Aluma) have been approved by the FDA for treatment of facial wrinkles. In some devices, a vacuum is applied to the skin in conjunction with the radio waves. Treatments can be prolonged and painful, multiple treatments over a period of months are required, and improvement may be less impressive than is generally seen with other options. Treatment costs are very high—several thousand dollars per treatment—and numerous anecdotal reports question their cost/ benefit ratio. Physicians did not develop a standardized protocol for radio frequency treatments until the spring of 2005, which means that useful statistics regarding safety and long-term effi cacy will not be available for some time.

Nitrogen Plasma

Another evolving rejuvenation technique, nitrogen plasma treatment, consists of energy delivered to the skin by way of ionized nitrogen gas pulses. One machine, the Portrait PSR3, is on the market. Nitrogen plasma treatments can be ablative or nonablative and are moderately painful. As with other options, a series of nonablative treatments must be performed to achieve the desired effect. Longterm benefits or advantages of this technique over other treatments have not been proven. Other Skin and Hair Procedures

Hair Transplantation

Both men and women can suffer from hair loss, although women tend to have more diffuse and subtle loss than men. Hair replacement surgery is performed mainly on men and is discussed in Chapter Ten.

Laser Hair Removal

Permanent hair removal has become very popular since the development of technology that permits effective hair reduction with limited risks to skin. The technology uses laser energy, IPL, or other energy sources such as microwaves. Laser hair removal is performed in an office or spa setting, usually without anesthesia. Multiple treatments are required and are spaced several months apart. Patients may develop redness or crusting that may take several days to resolve. The degree of permanent hair reduction varies considerably from patient to patient, depending on skin and hair color and body location. Light colored hair cannot be significantly reduced with current technology.

Laser hair removal is moderately painful. Some patients elect to use prescription or over-the-counter topical creams containing lidocaine or a related anesthetic in order to reduce the discomfort of treatments. Major complications of laser hair removal include scarring, permanent skin color changes, and topical anesthetic overdose. The bottom line: Laser hair removal can lead to permanent reduction of coarse dark hair, although multiple treatments are always necessary. Laser hair removal is one of the common cosmetic procedures performed without direct physician supervision, despite risks of serious or even fatal complications.

Skin Pigment Correction

Patients with skin pigment problems may have areas of too much color (hyperpigmentation) or too little color (hypopigmentation). Birthmarks, moles, sun damage, and tattoos are a few of the most common causes of undesirable skin pigment. Pigment irregularities are a well-known potential complication after all forms of skin resurfacing and laser treatments, especially with any subsequent ultraviolet light exposure. Treatment options for hyperpigmentation include topical bleaching agents, surgical excision, laser treatments, and chemical peels, but each condition requires a correct diagnosis before an appropriate treatment plan can be developed. Lasers might seem like the perfect tool for pigment reduction, but in fact, most lasers have limited usefulness because their effects are either too specific or too broad. Unwanted pigment is often present in more than one skin layer; narrow target lasers miss some pigment and broadly destructive lasers are too likely to cause scarring. Therefore, although many pigment conditions require more than one type of laser for maximal eradication, most physicians do not have the luxury of access to a large variety of lasers.

When considering treatment of a pigmented lesion, patients should know that (1) lesions with any potential for malignancy should be removed intact and examined under a microscope; laser or other destructive treatment of many moles is not appropriate for this reason. (2) Resurfacing procedures may help reduce the extent of many types of hyperpigmentation, but the risks of creating new pigment irregularities are increased in darker skin types. (3) Complete removal of undesirable pigment in biological lesions and tattoos is often impossible, and the resulting blotchiness or blurred image may not be an aesthetic improvement over the original condition. (4) Regardless of treatment, recurrence of biological hyperpigmentation is common, especially in patients with sun damage who are not willing to be compulsive about protection from the sun.

Too little skin pigment (hypopigmentation) can be congenital (vitiligo) or related to injury, even in the absence of scarring. There is no good treatment for loss of skin pigment. Tattooing rarely leads to a natural result. Makeup is usually the best, albeit temporary, treatment.

Scar Revision

Scar revision is by definition a reconstructive procedure but is often not covered by insurance. Scars can rarely be eliminated but often can be improved. The choice of treatment depends on the nature and location of the scar; options include surgical revision, resurfacing procedures, filler injections, laser treatments to diminish redness, and steroid injections. A combination of surgical and nonsurgical treatments may work best, and treatments may have to be repeated.

Stretch Marks Treatment

Stretch marks (striae) result from the degradation of skin structures and often develop as the result of hormone influences. They are a cosmetic concern for many people, but for all practical purposes they are permanent. Numerous treatments have been reported to eliminate stretch marks, but there is very little scientific evidence as to the effectiveness of these treatments, and almost no studies comparing the relative efficacy of different treatment modalities and combinations. Reported treatments include the use of various types of lasers, topical vitamin A derivatives, microdermabrasion with and without ultrasound, and sonophoresis. Some treatments do reduce the visibility of red stretch marks, especially in light skin, but improvement is usually limited to appearances with no actual change in the skin structure. Mature (flat and faded) stretch marks are less likely to respond to any form of treatment. Treatment options are especially limited for darker skin types.

The bottom line: Under the best of circumstances multiple treatments over several months may yield slight to moderate improvement in the appearance of stretch marks in carefully selected patients, and continued maintenance treatments will likely be required.

Micropigmentation

“Micropigmentation” is the medical term for tattooing. Tattooing has an important place in reconstructive plastic surgery, most commonly as a component of nipple reconstruction after breast cancer surgery. As a cosmetic procedure, micropigmentation refers to the instillation of pigments as permanent makeup.

Micropigmentation is an offi ce procedure and may be performed by a nonphysician. Two or more procedures may be required to achieve the desired effect. Pigments must be approved by the FDA, occasionally cause allergic reactions, and can interfere with magnetic resonance imaging scans. The most common complications of medical tattooing are those related to operator error. Poor placement, excess or insufficient instillation, pigment spread, scarring, or permanent local hair loss can occur if the procedure is improperly performed. Unfortunately, many women underwent permanent eyeliner tattooing in the 1980s by physicians who did not have a clue where to apply makeup and who had received very little training in the design aspects of cosmetics application when they purchased their machines.

Like all tattooing, micropigmentation should be considered permanent. In some cases laser treatments may be the only option for tattoo removal, and the laser energy itself may damage hair follicles or may not succeed in removing all of the pigment.

Destruction of Skin Blood Vessels

Prominent skin blood vessels that are treated for cosmetic reasons fall into two main categories: small vessels (telangiectasias) and angiomas, mainly of concern on the face, and leg veins. Large leg veins are treated primarily by vascular surgeons. Smaller veins are treated by a variety of cosmetic medical providers using the methods described below. Port wine stains are red or purple birthmarks that often can be, at least partially, ablated with the same lasers that are used for small blood vessels. Treatment of port wine stains, particularly in children, may be covered by insurance.

Vascular Lasers

Lasers are now the gold standard for treatment of undesirable small skin blood vessel lesions and have replaced the old technique of cauterization. Facial spider veins (telangiectasias) are especially common in fair, sun-damaged skin and are usually treated with a laser and without anesthesia in an office or outpatient surgery facility. The pulsed dye laser is the type of laser most commonly used. Multiple sessions are almost always required, and although treatments can be performed without causing bruising, power settings that do lead to bruising usually result in faster clearing of the blood vessels. Bruising usually takes two weeks to resolve and some residual brown discoloration will take another two weeks or more to disappear. Swelling is common when large areas are treated, especially near the eyes. Scabbing can occur with high power settings and may take days or weeks to resolve. Scarring is rare but not impossible, and permanent changes in skin pigmentation may develop, especially in patients with darker skin. Laser destruction of facial blood vessels is permanent in that totally closed vessels usually do not reopen. However, the eventual development of new telangiectasias is virtually guaranteed in susceptible skin. Angiomas are the bright red, well-defined bumps often seen on the chest and abdomen. Angiomas can be effectively destroyed with lasers.

Spider veins of the legs, in contrast to those on the face, are best treated with a combination of therapies. Even small superfi cial leg vessels have a high rate of reappearance after laser treatment alone. Therefore, leg vein therapy usually must include surgical treatment of related varicose veins followed by sclerotherapy (see the following section) of all but the smallest vessels. Laser treatment is reserved as the last step of the leg vein treatment program. As with sclerotherapy, laser treatment of leg veins can lead to permanent hyperpigmentation.

Sclerotherapy

Sclerotherapy refers to the injection of an irritating substance through a small needle into a blood vessel for the purpose of causing that vessel to close and thereby become invisible. Sclerotherapy was invented decades ago in order to treat small leg veins and is sometimes used on other parts of the body, including the face and hands. Various solutions are used for injection; Sotradecol is one of the most common. Injections are performed in the office, usually without anesthesia. Multiple injections over multiple office visits is the rule, especially for leg veins. Patients undergoing leg vein injection may The Cosmetic Medical Care Product Line 195 be required to wear heavy elastic stockings for a week or more after each injection.

Sclerotherapy is generally safe, but the main undesirable side effect is permanently increased pigmentation of the skin at the vein site, especially on legs. Skin breakdown over the injected vein can also occur, which is likely to lead to scarring and pigment irregularities.

Drug Delivery Systems

Numerous pro cesses (and gimmicks) have been described that purportedly help the skin absorb skin-care products, chemicals, and drugs. You may hear about things that vibrate, stimulate, conduct, infuse, hydrate, abrade, nourish, massage, and suction in conjunction with the topical application (not injection) of substances into the skin. The implication is that by forcing the substance into the skin, a beneficial response will be seen. Although much of what is claimed about the effects on skin by chemicals delivered by these methods has no basis in science, there is some evidence that select technologies may enhance the transdermal delivery of certain kinds of molecules. For example, in sonophoresis, low-intensity ultrasound is used to facilitate the transport through skin of topically applied drugs. Recent studies have looked at the delivery of various topicals by way of sonophoresis after the skin’s barrier layer has been disrupted by microdermabrasion. The effectiveness of this technique for the purposes of skin rejuvenation is yet to be proven. A Few More Words about Lasers in Cosmetic Medicine Most people have a somewhat fantastical vision as to what lasers can do. In fact a laser is simply another tool that a surgeon may use. Certain procedures are performed far more effectively with a laser than with any alternative: Hair removal and destruction of spider veins on the face are good examples of this. Other lasers provide an alternative among several for surgeons who are trained in both laser and other techniques. Procedures will nearly always be priced higher than the alternatives if the cost of a laser must be covered.

In general the following information applies to most laser treatments:

• Despite what sales reps and some providers would like you and your surgeon to believe, a laser has not been invented that treats all conditions well. • Long-term comparative studies of the effectiveness of cosmetic lasers are virtually nonexistent. • Laser treatments can be painful. Many lasers are equipped with some type of cooling mechanism to help reduce discomfort. Some type of anesthesia, ranging from topical creams to general anesthesia, may be necessary in some circumstances. • Regardless of the condition being treated, multiple laser treatments are almost always required for substantial benefi t. • Laser treatments to the face tend to cause Herpes simplex outbreaks in susceptible patients who are not pretreated with antiviral drugs.

Dental Cosmetic

Cosmetic dental work has become very popular and can be just as expensive as major cosmetic surgery. Certainly, the smile makeover is a big component of Extreme Makeover and similar television shows. Not a few patients on those shows have undergone dental procedures that appear to have been chosen in lieu of more complex and time-consuming, although arguably more appropriate, surgical treatment. Like cosmetic medicine, cosmetic dentistry is big business. Well-known entrepreneurs like Dr. Bill Dickerson have established institutes and give motivational speeches and marketing advice for dentists looking to expand their cosmetic practices.

No one is sure how many cosmetic dental procedures are performed annually in the United States. Since 1996, the American Academy of Cosmetic Dentistry has doubled its ranks to about 4,700 members. Cosmetic dentistry is not a separate subspecialty of dentistry, and most dentists incorporate at least some cosmetic procedures into their practices. Dentists aiming for high-volume cosmetic practices may invest heavily in advertising and may use tools like computer imaging to help sell restoration work. Cosmetic dentistry is rarely covered by insurance, and the cost of some procedures can easily exceed $1,000 per tooth.

As with cosmetic medicine the current popularity of cosmetic dentistry is in part related to recent improvement in materials and technology. For example, the newer composite resins and cements allow better color matching and color stability and permit repairs that in the past would have required major crown work. Common cosmetic dental procedures include the following: • Bleaching for stained or discolored teeth • Tooth- colored composite fillings for chips, cracks, small gaps, and rough areas • Recontouring for uneven teeth • Porcelain veneers for large gaps or extensive imperfections • Tooth-colored porcelain crowns for more severe irregularities • Orthodontia (braces) for tooth straightening Just as with cosmetic medicine, there is often more than one dental option to correct a partic ular problem. Some options are quite time consuming but may be preferred because they offer a better or sturdier long-term result. Potential patients are advised to research their options. Even more important, patients should think long and hard about how much permanent change in their appearance they are willing to make. Look at the contestants on cosmetic surgery reality shows carefully; chances are you will understand why some pundits call those expensive porcelain veneers “Chiclet teeth.” Alternatives abound in the marketplace for those who have less money to invest: A row of removable prosthetic “false veneers,” custom-made to hook over your existing teeth, can be purchased for “only” $2,000 to $3,000.

Skin Care and Products

Providers often advise patients to use topical products at home as part of a rejuvenation regimen. The chemicals in these creams fall into several main categories: vitamin A derivatives (retinoic acid, tretinoin, retinol, tazarotene); diluted glycolics (acid peel chemicals); sunscreens; bleach (hydroquinones); copper peptide formulations; moisturizers; and various other “enhancements” (for example, vitamin C, vitamin E).

The popularity of noninvasive prescriptive skin treatments has provided a huge boost for over-the-counter skin-care and cosmetics manufacturers. Many of the same chemicals prescribed by cosmetic surgeons and dermatologists are available in a diluted form and incorporated into products found on the shelves of grocery stores, department stores, drugstores, and salons. Marketing rhetoric for these products typically includes references to more invasive cosmetic interventions. “If you think cosmetic procedures are too drastic, do we have an alternative for you” is the tagline for one Olay product. Another claims to provide microdermabrasion and chemical peel all in one package. Some over-the-counter lines of skin cleansers, moisturizers, and cosmetics are sold only by physicians, ostensibly so that patients will get better information about their use but also because they can be retailed at a much higher price that way.

Consumers are interested in “natural” products, and advertising usually emphasizes bio-ingredients such as collagen and plant extracts. Some of these ingredients have been used for centuries in folk remedies and in some cases do have active biological properties. However, there is little to no scientific evidence from clinical trials that these ingredients are safe or effective or that they even penetrate beyond the skin’s surface layer of dead cells.

Over-the-counter products containing both drugs and cosmetics, herbs (previously called botanicals), or “nutrients” are called “cosmeceuticals,” “herbaceuticals,” and “nutraceuticals,” although these words are not recognized by the FDA as categories. The FDA does require that substances containing both cosmetics and drugs meet the standards for both categories.

Skin care is the subject for an entire book of its own, and there may be more useful scientific knowledge about various ingredients in the future (keeping in mind that relevant controlled clinical studies are rarely performed in the cosmetics and skin-care industry). Still, a few comments are in order about nonprescription products:

• Skin cleansers and moisturizers. These products should be expected to do just what their labels say: clean the skin and add moisture/slow moisture loss. Use what you like; the ingredients are irrelevant except for sunblock. Having said that, waterbased products provide less moisturizing than do oil-based products.

• Sunscreens. Sunblock is essential, and a product containing a sunblock should be worn daily, at least on the face, and reapplied frequently. Some moisturizers contain sunblocking agents but if yours does not, you should apply a sunblock before you apply moisturizer. Look for a sunblock with SPF 30 or higher. Protection against both UVA and UVB is essential, since both wavelengths are damaging. Unfortunately, sunblocks currently available in the United States do not have good UVA protection, even though effective products for that purpose are available in other countries. The reason is that products containing sunscreens are considered drugs by the FDA and must go through the expensive premarket testing pro cess and get FDA approval before they can be sold. One well-regarded and reportedly very effective product, Mexoryl, was submitted by its manufacturer L’Oréal to the FDA for approval in 2001 but is still not available legally in the U.S.

• Tanning products: Some tanning agents are probably safe and some are known to be dangerous. In summary:

• DHA-based topicals. This is the only sunless tanning product approved by the FDA and is for external use only. The active ingredient, dihydroxyacetone, causes the outermost cells of the skin to turn brown the same way that certain sugar-containing foods turn brown in storage. This is the ingredient found in salon or home spray-on tanning products. DHA is not a sunscreen and should not be used as such.

• Bronzing gels. These are the dyes found in many cosmetic products that coat the skin with color.

• Tan accelerators and tan promoters. Some of these products contain tyrosine and theoretically can increase melanin (natural skin pigment) production, although this has not been proven. Others are based on bergapten (5-methoxypsoralen, 5-MOP), which is found in bergamot oil. Bergapten increases the skin’s sensitivity to ultraviolet light, intensifi es skin redness, and stimulates skin cells to produce melanin. It is also phototoxic and photocarcinogenic. The FDA considers all of these products to be unapproved drugs and has issued warning letters to manufacturers.

• Tanning pills. Most of these contain the color additives betacarotene and canthaxanthin. After ingestion these substances enter the blood stream and are partially deposited in skin tissue, giving the skin an orange-brown color. Neither color additive is approved by the FDA for this partic ular purpose, and products containing them are considered adulterated. Adverse reactions reported with tanning pills include stomach cramps, hepatitis, nausea, diarrhea, hives, aplastic anemia, and deposition of color in the retina of the eye.

• Antiwrinkle creams. These products come in many formulations, but the two active ingredients with which there is the most experience are the retinols and the AHAs (glycolic acids, lactic acid, and so on). The concentration of these ingredients is far less than that available in the corresponding prescriptiononly retinoids (Retin-A and Renova) and AHA peel solutions. These products will act like exfoliants and may make wrinkles appear less prominent, but there is little evidence that they have a significant long- term effect on skin. Formulations containing copper peptides may have a similar effect.

• Lip “plumpers”: Topical lip plumpers contain either an irritant that causes swelling or absorptive microspheres that fi ll in grooves. Both types of products temporarily (for hours or days) may make lips appear marginally fuller. Individuals prone to Herpes simplex outbreaks might do well to avoid substances that irritate the lips.

• Numerous other ingredients, such as growth factors, vitamin E, vitamin C, omega-3 fatty acids, other antioxidants like idebenone, and collagen, are hyped during product promotion. Some, such as argerilene and acetyl hexapeptide-3, are supposed to act like Botox without the need for injection. In their present formulations there is no evidence that these ingredients can penetrate the skin for benefi cial effects.

When evaluating any skin product, keep in mind that intact skin is supposed to act as a protective barrier, and effective transdermal (through the skin) delivery of a product or medication requires it to be in a highly concentrated form. Sometimes no tests at all have been performed on human skin using the final product, that is, after the hyped “active ingredient” has been added. Whether or not a chemical is a potent antioxidant, for example, is irrelevant if the chemical is deactivated the minute it sees light or air or if it cannot penetrate the skin’s surface.

COSMETIC MEDICAL GRAB BAG

The “We Just Don’t Know” Category Nearly everything on the cosmetics and skin-care shelf, as well as many supplements and not to mention most new technology, belongs in the “Who knows?” category. The difficulty lies in sorting out the science from the sales pitch, and most of the time there just isn’t any science to sort. Instead, we get verbiage like this: “Unique, patented formula of proven ingredients helps stimulate (skin, cells, collagen, metabolism, per for mance) and reduce the appearance of (wrinkles, fine lines, aging, sun damage).” This doesn’t actually mean anything from a scientific analysis viewpoint, but it sounds impressive, doesn’t it?

A few ingredients in this category have received quite a bit of press recently:

• Kinetin

• Peptides

• DHEA (dehydroepiandrosterone)

• Genetics- based custom topicals

The “We Don’t Know AND It Could Be Dangerous” Category

• Growth hormone. Human growth hormone sales represent a growing segment of the antiaging market, despite the fact that there is no scientific evidence that declining growth hormone levels cause aging or that taking growth hormone supplements can stop or reverse the signs of aging. In fact, animal studies suggest the opposite. More important, many patients taking growth hormone have suffered significant side effects, including behavioral changes, and users may be at increased risk for cancer and cardiovascular disease. There are only two strictly defined conditions in adults for which the FDA has approved growth hormone treatment, and all off-label uses (including athletic enhancement, antiaging, and age-related conditions) are illegal. This stands in marked contrast to many other drugs for which off-label use is permitted in appropriate circumstances.

• Breast-enhancing pills. Several dozen herbal products are advertised widely as “natural” breast-enhancing substances. However, there is no scientific data to support these claims, and risks, including adverse interactions between these herbals and other medications, are a major concern.

• Melatonin. Melatonin is a brain hormone that can be useful in the treatment of jet lag and sleep disturbances in people who The Cosmetic Medical Care Product Line 203 work night shifts. Some purveyors of antiaging treatments claim that melatonin provides, among other things, broad anti-oxidant and immune system benefits. In fact there is no science to support these claims, and no one knows if the long term use of melatonin for any purpose is effective or safe. Like many other products sold over-the-counter, melatonin is unregulated, and the concentration or even presence of melatonin in a product labeled as such should not be assumed.

The “Too Good to Be True” Category

• Facelift creams. Here is a great example of over-the-top marketing. A facelift cream is promoted as containing DMAE (2- dimethylaminoethanol). This chemical has been called a smart drug because it has led to a slightly longer life span in laboratory animals. So the ads for the facelift cream call the ingredient a “life-enhancing substance.” Impressive, but meaningless for humans.

• Facial muscle stimulators that substitute for a facelift.

• Light “wands” that presumably work like IPLs or lasers.

• At-home lasers that can eliminate skin problems.

• Body-shaper creams. I love the ad copy for these: “The at-home alternative to liposuction.” “Proven to tuck the tummy and lift the rear in four weeks.” This company offered a money- back guarantee—at two weeks.

• Creams to get rid of stretch marks or cellulite.

• Topical creams that substitute for collagen injections, Botox, and so on. These creams often contain ingredients that just happen to have trade names very similar to those of the items whose effects they purport to mimic.