Dr. McDaniel

Our culture would like to imagine that science and technology can be aggressive in winning this epic battle against aging. A proliferation of glitzy television programs currently promotes this as an easy dream, compressing long surgeries and prolonged recovery times into 30-minute segments portraying the transformation of people through the wonders of cosmetic surgery. It is theatrics at its best — and worst: immediate beauty for an impatient society that wants instant gratification.

So what does our culture really desire? Age-reversal surgery after time has already taken its toll? Or true anti-aging medicine that works to delay or avoid age-reversal surgery (or at least maintain the benefits of age-renewal surgery)? While I believe our culture wants both, it seems that the play-now-and-pay-later attitude, for the most part, prevails.

The effects of heredity, once thought to be unalterable, are increasingly within our grasp to manipulate and modify through new scientific developments. More choices are on the horizon, and new developments in gene research hold the keys to the future for many of these patients.

We need to return to the basics by using full-spectrum sun protection, avoiding tanning bed use and smoking, and minimizing exposure to other known environmental factors that negatively impact people's health. This is the cornerstone of true anti-aging healthcare.

The saying "we are what we eat" is becoming even more relevant today as the role of diet and optimal nutrition becomes better defined. As personal genetic testing becomes more widely available (and this is really not that far down the road), our ability to custom-tailor diet and nutritional supplements should dramatically increase. Also, there will be increased awareness of the specific health problems to which a person is especially predisposed (or from which he or she is relatively protected). Our genetic heritage is key to our future health.

The need for scientifically sound research on which our patients can base their treatment plans will become even more critical. Consumers are already lost in a sea of data and tossed about by contradictory advice; they are like a rudderless ship in a storm, without a compass or a captain to guide them. If we as physicians and scientists do not step in, others will — to the likely detriment of all parties.

More than ever before, now is the time for us to rise to the task and assume a leadership role, not only in anti-aging medicine and age-reversal surgery, but in true, scientifically based, anti-aging preventive medicine. We need to improve both our educational and our research programs.

The anti-aging movement is growing rapidly. Will your patients turn to you for advice? Will science or the marketplace prevail? The followers are there, but who will lead? Will it be you?

S-Caine Peel is a relatively new topical anesthetic that´s applied as a cream, solidifies as a mask or film, and then peels off.

Dr. Zachary, clinical professor and co-director of the Dermatologic and Laser Center at the University of California, San Francisco, says the physician should try to create a relaxed environment — what he calls "a bubble of comfort" — by displaying quiet confidence and making sure the patient understands everything about the upcoming procedure, and thus is comfortable with it.

Dr. Zachary discussed the "bubble of comfort" and other topics concerning anesthetics during his presentation, "Anesthetics for Cosmetic Procedures," at the recent Cosmetic Dermatology Seminar here.

Increasingly, it also goes beyond having just the patient, physician and/or physician's assistant present during the procedure.

Patient comfort "The concept of patient advocacy is gaining momentum," Dr. Zachary says. "In short, this is the idea of patients choosing a friend or family member to be with them, either through the entire process or just the procedure itself. It's just another way to help the patient feel more relaxed and at ease."

Other methods Dr. Zachary cites are rather basic, but are sometimes overlooked. It's important that the bed on which the procedure takes place is comfortable, that it has a soft covering, that warm blankets are at hand, and that music — preferably the kind the patient enjoys — is available.

Dr. Zachary says the benefits of all this attention to patient comfort is that the more relaxed and comfortable the patient is, the lower the patient's blood pressure will be and, generally, the lower the possibility of complications occurring during a procedure.

"There is also the fact that it's important for the physician to be as relaxed and comfortable as possible," Dr. Zachary says.

Topical anesthetics As for the anesthetics themselves, Dr. Zachary focuses on the topical variety: the creams and ointments that traverse the skin to nerve endings in the dermis.

"The benefits of the topicals is that they don't involve needles, often a big plus when you're talking about patients being relaxed, and they're more convenient to use — in some cases, they can be applied by the patient before coming into the office for the procedure," Dr. Zachary says. "On the downside, there is often a cost factor and there are varying degrees of efficacy among topical anesthetics."

Dr. Zachary says there are some issues with topicals related to the extent to which they've been tested.

"My advice is to keep to the topicals that have been thoroughly tested, because there are those out there that haven't been," he says. "With whatever topical anesthetic you choose to use, proper application is critical. Each manufacturer's instructions should be followed to the letter, and it's especially important to thoroughly educate the patient about this in cases where the patient is applying it before coming in for the procedure."

Atlanta — A new therapy visibly improves the quality of hypertrophic scars without any surgical intervention, according to Wolfgang Meyer-Ingold, Ph.D., director, Wound Healing Research Unit at Beiersdorf AG, Hamburg, Germany.

A scar following resection of a sapheneous vein shown before treatment and after eight weeks of treatment.

Research conducted by Beiersdorf showed that "scars are accepted out of necessity," Dr. Meyer-Ingold says. "People do not know of effective self-medication, and they don't consider professional help such as surgery, laser or abrasion to be an option because it is risky and too expensive. Consequently, people simply tend to hide scars with make-up or clothing."

"The polyurethane matrix does not lead to moisture accumulation under the patch, and therefore avoids side effects like itching or maceration," Dr. Meyer-Ingold says. In addition, the polyurethane matrix is hypoallergenic, reducing the likelihood of an adverse reaction at the site of application. After several weeks of use, the therapy softens the surface of the scar, flattens it and reduces redness.

The clear pad is available as a set of self-adhesive patches (2.75 in. x 1.5 in.) that the patient uses to cover the scar. Larger scars may be treated with two or more patches. Application of the patch is simple. The scar area is washed and dried, and the patch is applied and secured over the scar. For best results, a patch should remain on the skin at least 12 hours a day. The patch is changed daily for at least three weeks, after which results first become visible, with the therapy continued preferably until eight weeks.

The polyurethane clear pad was compared to a silicone-based adhesive pad (Mepiform, M�ycke Health Care, Helsinki, Finland) in a 12-week, open-label, observer-blind, intra-individual clinical trial evaluating the efficacy of both products for scar therapy. The polyurethane pad rated significantly higher in overall scar index at both four weeks (p<0.001) and eight weeks (p=0.012).

Kick start the remodeling "After wounding, nature has a higher need for fast healing than for cosmetic results," Dr. Meyer-Ingold says. "Remodeling takes place after wound closure, and the two factors that have been identified as essential to the remodeling process are temperature and pressure. CURAD Scar Therapy applies slight pressure upon the scar and raises the scar temperature." The pressure exerted on the scar by the clear pad is 15 to 20 mbar.

The surface temperature of a scar is slightly lower than the surface temperature of the surrounding skin. A slight increase in scar temperature increases the activity of collagenase and stimulates cells to produce more collagenase, a critical enzyme in the remodeling process.

"CURAD Scar Therapy provides a local thermal insulation of the scar, hindering the body's heat radiation from the skin into the environment," Dr. Meyer-Ingold says. Measurements have shown that CURAD Scar Therapy raises the temperature by approximately 1 degree Centigrade.

In addition, use of the polyurethane pad was shown to improve microcirculation in the scar tissue. The resulting increase in blood flow to the scar area further supports or activates the normal remodeling process.

"CURAD Scar Therapy works by physically stimulating the body's own remodeling mechanism," Dr. Meyer-Ingold says. Small-scale clinical studies in Europe have suggested that the therapy might also be effective when used prophylactically to prevent fresh hypertrophic scars after surgery.

On call art

The majority of procedures — including microdermabrasion and resurfacing — stem from a need to correct scarring, much of it from acne.

The next largest category is rhinoplasty procedures, some of which are performed in conjunction with the correction of breathing problems. Others, however, are done purely for cosmetic reasons. A number of cosmetic surgeons consider the self-esteem issues involved with a large or differently shaped nose.

For a rising number of teens, breast augmentation is the new "in" thing while liposuction is considered a way to reshape even a teenager's body.

Nearly 4,000 patients 18 years old or younger had breast augmentations last year. Another 4,000 had collagen injections, and just more than 3,000 liposuctions were performed on the teenage set.

Cosmetic Surgery Times asked cosmetic surgeons whether they accept teenage patients, and, if so, if they use the same guidelines as they do with adults.

We also asked doctors if they see any problems arising from performing teen cosmetic surgery.

Most restrict patients Most surgeons who spoke to On Track say they restrict their patients to those 18 years old or older. They say that they might skew the figures for "teenage" cosmetic surgery, because in virtually all states, an 18-year-old is considered an adult, but is also still considered a "teenager" for purposes of the reports.

Bruce A. Wolf, M.D., from Elizabethtown, Ky., says, "I don't do anyone younger than 18, unless it's a congenital problem. I will do rhinoplasties on kids who can't breathe, but generally, I like to wait until the growth of their face is complete, and that's usually about 16 or 17."

Because 18-year-olds are considered adults, for many physicians that's the age at which they will consider performing procedures such as breast augmentation or liposuction.

Dr. Wolf says that's generally when he will see those patients.

"If you're doing something cosmetic with the breasts, generally the implant companies don't like you to use them on a young patient. Our (professional) society also believes that, and recommends that unless patients have a congenital problem such as one breast being smaller than the other, that 18 be the age for surgery."

Cole Goodman Jr., M.D., of Fort Smith, Ark., says he believes teenagers' desire for cosmetic surgery is actually decreasing.

"The thing that younger people have traditionally shown interest in — girls and boys — is rhinoplasty, and I'm just not seeing that as much as I was 10 to 15 years ago. I just don't think it's as big a deal as it used to be.

"We are getting more inquiries about liposuction and we've had inquiries about breast augmentations. I've just set an empiric minimum of 18 for my practice," he says.