Perhaps the most common question patients ask about wrinkle fillers (after “will I look natural?” and “will it hurt?”) is “how long will it last?” And the answer, of course, is it depends upon how you define “lasts.”

Wrinkle fillers are used to minimize the folds that run from the nose to the corners of the mouth, the marionette lines that bracket the chin, and to replace the lost volume in the cheeks. A correction is usually at its peak the first week after it is performed and begins to lose its effectiveness over time in a somewhat linear fashion such that a filler that would be expected to last a year will be somewhat less than half absorbed in six months. Patients who smoke, have a high metabolic rate, or are very athletic will note the volume of their correction will diminish more quickly.

Hyaluronic acid-based fillers such as Restylane® and Juvederm® typically last from seven months to a year. Fillers such as Juvederm are approved by the FDA to last “up to a year.”

The calcium-based fillers such as RADIESSE® are generally thought to last a year or more. There are other, longer-lasting fillers such as ArteFill that will last even longer but those products can have other problems that preclude their use in my office. Products such as Sculptra® are not wrinkle fillers but are, instead, collagen builders and can last up to two years but require at least three initial treatments over a month and a half.

The answer then should always be “it depends.” And the solution, for almost everyone, is to proactively address the longevity issue by replacing the product before it is all gone. There is simply nothing that will make it last longer.

Richard M. Foxx, MD is the Founder and Medical Director of The Medical and Skin Spa in Indian Wells, CA. He may be reached at 760-674-4106 or at drfoxx@medicalandskinspa.com

Back in the good old days, say about 10 years ago, there were only a few ways to fix sun-damaged skin—peels, or ablative laser skin resurfacing using the CO2 or Erbium laser. Those lasers usually required some form of sedation or even anesthesia and were associated with several weeks of downtime during which the skin healed from what amounted to a deep second-degree burn. They often left the treated skin a lighter color.

If you didn’t want to undergo that kind of therapy the alternative was for your aesthetician to do a peel and peels became the stock-in-trade of aesthetic medicine for brown spots, large pores, softening lines and wrinkles, as well as for improving acne. For a while it seemed that every skin care guru was devising a proprietary peel, from Jessner to Obagi, using tri-chloro acetic acid (TCA) and other acids in some arcane combinations.

With the advent of the non-ablative lasers such as CUTERA’s™ Genesis and XEO and the Intense Pulsed Light (IPL) systems, skin improvement could finally be achieved without downtime. When fractional skin resurfacing with FRAXEL and other technologies was developed in about 2002, lasers took another giant step forward and it became possible to achieve, without downtime, many of the results previously only possible with the ablative lasers.

Aesthetic medicine is nothing, however, if not dynamic. What is hot one day is not the next and peels, it seems, are now coming back into vogue. Formulated with many innovative ingredients along with TCA such as azelaic acid, salicylic acids, and glycolic acid, the new generation of peels such as the VI Peel are more effective with less downtime. Even more important is the idea that these peels can offer a less expensive and yet viable alternative to laser therapy for certain skin problems.

And as with all aesthetic and laser medical procedures it is important make yourself as knowledgeable as possible, to review before and after pictures, to know who is doing the procedure, how it will be done, and to know how many your Doc’s office has performed.

Richard M. Foxx, MD is the Founder and Medical Director of The Medical and Skin Spa in Indian Wells, CA. He may be reached at 760-674-4106 or at drfoxx@medicalandskinspa.com

For years the medical profession has been aware of the benefits that accrue when patients take the time and make the effort to care for themselves. In the last few years, however, we have become increasingly aware of the improvement in general health when we take the time to improve our appearance.

Not long ago a group of physicians in the UK published several papers showing that patients who used effective cosmeceutical products and who underwent regular maintenance treatments were more likely to eat healthy foods and follow a workout program. The result was a general improvement in quality of life and a decreased incidence of depression.

Just recently, researchers from the University of Southern Denmark tracked almost 1800 sets of twins and found that perceived age was significantly associated with survival. Not only was there an association between perceived age and physical and mental functioning, they also found the bigger the difference in perceived age, the more likely it was that the older-looking twin died first.

That’s a good nugget to remember next time someone says that aesthetic medicine is all about fluff.

Richard M. Foxx, MD is the Founder and Medical Director of The Medical and Skin Spa in Indian Wells, CA. He may be reached at 760-674-4106 or at drfoxx@medicalandskinspa.com

by Richard M. Foxx, MD

If you were on Jeopardy the answer might go something like this: “The most effective, predictable, and clinically-proven pharmaceutical product used in cosmetic dermatology today.” The question, couched of course in the form of a question, would have to be “What is BOTOX®?”

So why is it that a product used more than four million times a year, a product that is at once reliable, dependable, and associated with fewer side-effects than just about anything else, be so badly misunderstood?

The answer to that is a little more complex. BOTOX has almost become a cliché, a symbol of what people do when they want to look younger and more relaxed. Written about almost monthly in virtually all of the “glamour” magazines, BOTOX is often lumped in the same category with dermal fillers and plastic surgery, and stirred around so much that all the casual reader remembers is a few disjointed facts.

Believing, with Madame Curie, that nothing in life is to be feared, it is only to be understood, herewith are just the facts based upon seven years of experience and over 3,000 patients personally injected by me.

BOTOX has been around since the early 1980’s. At first used to relax eye muscles in patients with lazy eyes it was up to a Canadian physician, Alistair Carruthers, to discover its application to facial wrinkles. After being used for almost 20 years and amassing an enviable safety record, it was finally approved by the FDA for use in certain areas of the face in 2002.

Unlike traditional drugs that have to be metabolized by the body before they begin working, BOTOX remains where it is injected. It is administered with a very tiny needle in or near the areas where muscle relaxation is desired and works by locally blocking the nerve impulse before the muscle can respond.

The blocking phenomenon is a chemical reaction that begins to work immediately but is usually not complete for three to five days. This explains why the full effects of BOTOX are not seen for that long. The body begins to overcome that block and finally succeeds somewhere in the third to fourth month when muscle activity returns. BOTOX does not have to be excreted in the kidneys or by the liver.

When I administer BOTOX, I start by determining exactly what each patient desires and what the facial anatomy calls for. After obtaining a picture, I apply a numbing cream for 10 to 15 minutes and then mark the areas where the product will do the most good. Prior to actually injecting, using a needle only slightly larger than a mosquito’s stinger, I apply ice to the actual injection site to make it even more comfortable.

Patients may return to work immediately.

BOTOX is an ideal way to get your feet wet and introduce yourself to the wonders of modern cosmetic dermatology.  Find the most experienced injector you can by asking around, have the brief, relatively painless treatment, and watch the years melt away.

]]> http://blog.medicalandskinspa.com/2009/07/20/modern-medical-miracles-is-the-category/feed/ 0 http://blog.medicalandskinspa.com/2009/04/28/the-artists-eye/ http://blog.medicalandskinspa.com/2009/04/28/the-artists-eye/#comments Tue, 28 Apr 2009 21:43:19 +0000 drfoxx http://blog.medicalandskinspa.com/?p=51 THE ARTIST’S EYE

Richard M. Foxx, MD

Placing your face in a stranger’s hands requires a high degree of trust. You want to know that person is a careful, conscientious professional with a highly-developed sense of proportion. So how do you do that?

First, ask who exactly will be doing your procedure.

In most cases your choice would be a physician. In fact the Medical Board of California views many of these procedures as “the practice of medicine” and is quite specific as to who exactly may perform these non-invasive procedures. If performed by a nurse or physician assistant, California requires supervision by a physician capable of performing the procedure.

Of course not all practitioners are alike. Most physicians approach the attainment of cosmetic dermatologic goals from a doctor’s point of view. But just like music, writing, or painting, cosmetic dermatology requires a combination of training and inborn skills and talent. In the final analysis, a great result takes more than just an injection of BOTOX® or RADIESSE®, it takes knowing where and how to use these and other elements such as lasers and light therapy in a synergistic blend. In short, it requires an artist’s eye.

Second, ask how many procedures your professional has done. Numbers alone are no guarantee of a good result. As in sports, it’s not only practice that makes the champion; it’s practicing the right moves. But numbers are a good indication of previous success.

Third, ask to see before and after pictures. This is where you get a chance to judge for yourself if your doc’s sense of beauty and proportion match yours. Ask also to see pictures of patients who match your age and concerns and, if possible, ask for testimonials.

Getting the right answers to those three questions doesn’t guarantee that you will come out the other end looking perfect, but it’s a good place to start and if you get the right answers, it’s an unbeatable way to put your mind at ease.

It would be wonderful if all we had to do when we didn’t like something about our appearance was to fix that one issue. We could get out the magic eraser and remove the line or the fold or plump here or there and everything would be perfect. But we can’t, and that’s where the artist’s eye comes into play.

The face is a canvas of infinite variability where absolutely everything is interconnected. Our appearance is the sum total of a bunch of little things. It’s like one of those spreadsheet programs where if you change one thing here you get a cascade of unintended consequences there and over there. Seldom does just doing one thing work. In most cases, in fact, achieving a beautiful result that does not look overdone requires many small incremental steps.

As someone who has been involved in the creative process his entire life both with writing and with photography, Doc Foxx is able to approach each patient’s concerns with an artist’s eye.  From there he is able to select the correct modalities necessary to get as close to the desired result as possible.

The first part of this was written by David Lominska, arguably the most famous polo photographer in the US.  He is to polo what Ernie Pyle was to the troops in WWII.

Sam Morton wrote the second part.  He is a highly-regarded horseman, cowboy, and a much admired writer.

These words were forwarded to me and I share them with you.  In all the words that were said and will yet be said you must remember how much we love our horses.

RMF

Here goes:

It is the worst thing I have seen in 40 years with horses… Afterwards looked like a medieval battlefield with carcasses strewn about.

I wrote this to Teresa Gentile last night:

It’s been a couple days from Hell, Sunday was the worst thing I have ever seen in 40 years working with horses.

The Lechuza horses arrive at the field and as soon as they came off the trailers it was apparent something was wrong, they were staggering and stumbling and some started to drop.

Everyone immediately dropped everything and went to help, every Vet in the County was there, they had 6-8 people on every horse trying to keep them walking, holding them up. One by one they would drop and they would cover the horse with bags of ice (They sent a whole truckload from the ice plant) as their temps were spiking at 103-104.

I worked with security keeping the photographers away, none of the polo photographers were a problem but there were some Press photographers and just “looky-loos” with cell phones etc. I had to get in 2 guys faces and ended up having them dealt with by security. The horses were on the far side of the east lake so they were able to keep them isolated and park trailers in the way and put up screens around the downed horses. They quickly assembled a team and horses and threw together a short exhibition match to keep the fans in the stadium busy while they tried to deal with the crisis.

After about 2 hours virtually every horse that was affected was down and dead, there were one or 2 that they got to the clinic, but they succumbed during the night. There were several that died back at the barn as well, only three at the field that survived and I heard that they were the umpire horses. Last reputable total I heard was 21 horses in toto. Every horse died of pulmonary edema. There is going to be a huge investigation, blood has been taken for toxicology and every horse is going to be posted

Of course there has been wild speculation, unlicensed Argentine vets, dope cocktails, a hit on Victor Vargas… I spoke with Roberto Gonzalez, he is the team coach, and he said at the barn they were as baffled as everyone else. We all know how superstitious polo people are and they claim that they didn’t do anything different than they do before every match. They suspect a Selenium/potassium treatment they give to prevent tying-up, I remember giving something like that when I was grooming. What I can see happening is a mislabeled or misread bottle that had a higher, toxic dose being injected IM, usually when you give something toxic IV, the horse drops before you can get the needle out… we’ve all seen Combiotic that hits a vein accidentally.

The toxicology report should be back tomorrow sometime, and the PM’s by the end of the week, it is going to be a major deal to post all those horses and they will all have to be done.

It has been a media circus around here, even I have been turning down requests to speak on camera.

Frederic published an article from Sam Morton that I will copy below.

I have been trying to channel my feelings into poetry, haiku specifically, I have had these recurring images and for me haiku is very distilled and visual:

Crossing the river: 3 Haiku

Tentative steps
to the water’s edge, the mare
shows the herd the way.

One by one, the herd
in search of greener pastures
crosses the river.

On the other side,
their journey ended, they find
water, shade and rest.

This morning we had a tremendous thunderstorm after a winter of drought and many tragedies, one woman killed, another in a coma and then this.

No longer able
to hold our tears, even the
heavens are weeping

David

Our Black Sunday

By Sam Morton

“Nothing really prepares you for what happened Sunday; the horror of over twenty horses dropping at our biggest polo tournament of the year. Young athletes cut down in their prime. It is our Black Sunday or 9/11 in polo. There are lots of rumors running around which doesn’t really change the end result. Lots of horsemen who happened to be there scrambled over to help but there was nothing they could do. One witness told me it looked like there were twenty people around each horse trying to do something, anything.

“People who work behind the scenes in polo learn to work fast. We pride ourselves on it. Horses are tacked up, stripped, and washed in minutes. At the U.S. Open Sunday, and at any Florida function all winter, there are people from all over the world in the polo community. For over an hour, South Africans, Argentines, French, Americans, Canadians, Mexicans, Brazilians, Costa Ricans, Cubans, and several other countries, worked shoulder to shoulder with the best horse vets in the world to save lives. They were scrambling as one, at a moment’s notice. I can tell you no one could have worked faster in any sport, equestrian or human, and for that I am extremely proud to be part of it. The polo team, Isla Carroll mounted a substitute team in little over an hour. I’m not sure people realize what went into that.

“Grooms, sponsors, vets, players, photographers and spectators are all bonded by a passion for horses. It’s who we are as a community. The last time we were brought together was the herpes virus scare a few years back. I sat in a room and looked at pros, blacksmiths, grooms, vets, owners and fans of polo that pulled together for the love of our horses and I think it was probably the first time I truly thought about being part of a community. I was proud then and I am proud now.

“In Plains Indian society, less than two hundred years ago, it was believed that when a man dies, his horse would accompany him in the next life. That’s how much horses were deeply involved in their life, and in a way they are that much a part of our lives in polo. I can tell you every polo player, groom, owner, trainer and fan of the game fells the pain right now. We are deeply hurt and saddened as a people over the loss of our horses. To Lechuza we send our condolences.

“God bless the souls of our horses that run with the angels now.

“Gotta go.”

“My horse fights with me and fasts with me because if he is to carry me into battle, he must know my heart and I must know his or we shall never become brothers. I have been told that the white man who is almost a god, and yet a great fool, does not believe the horse has a soul. This cannot be true. I have many times seen my horse’s soul in his eyes.

-Plenty Coups Chief of the Crow”

Sam Morton

]]> http://blog.medicalandskinspa.com/2009/04/24/tragedy-in-polo/feed/ 0 http://blog.medicalandskinspa.com/2009/03/04/fraxel-in-perspective/ http://blog.medicalandskinspa.com/2009/03/04/fraxel-in-perspective/#comments Wed, 04 Mar 2009 19:49:00 +0000 drfoxx http://blog.medicalandskinspa.com/?p=43

FRAXEL® IN PERSPECTIVE

Richard M. Foxx, MD

After more than two years of experience with FRAXEL I continue to be impressed by the results—both short and long term.

While out and about I recently encountered a casual friend I had not seen in over a month. A contemporary, he originally signed on about for the treatments about six months ago because of extensive sun damage, brown spots, and actinic keratoses from years in the sun at the beach. I knew he had a good result when I saw him four weeks after his last treatment and took pictures but I was not prepared for the tremendous improvement he continued to have in skin coloration, texture, and improvement of fine lines. I was impressed. So was he. More importantly, so was his wife.

Another patient presented for follow up photos the other day four weeks after completing the series. A fair-skinned strawberry blond in her 50’s, she had multiple brown spots, many fine wrinkles under her eyes and around her mouth, and large pores. I was amazed at the improvement. The brown spots were gone, the peri-orbital wrinkles were 90 percent or more improved, and the wrinkles under her eyes were undetectable.

Since we opened this office, my litmus test for any piece of equipment I bring into the office is simple: Will I be pleased when I take my after pictures or will I be squirming in my seat doing a little soft shoe and trying to find improvement that isn’t there?

With FRAXEL I was impressed the first time I saw the system demonstrated. The more I looked into it, the more impressed I became. The impressive safety record sealed the deal and we began to do treatments in January of 2006, before any other office in the desert.

Since then I have never regretted the decision. I wish I could say that about every decision I ever made.

Doctor Foxx is the Founder and Medical Director of The Medical and Skin Spa, a medical skin clinic in Indian Wells, CA, at Hyatt Grand Champions Resort, one of the country’s only resort-based medical spas.  He may be reached at drfoxx@medicalandskinspa.com or at 760-674-4106

]]> http://blog.medicalandskinspa.com/2009/03/04/fraxel-in-perspective/feed/ 0 http://blog.medicalandskinspa.com/2009/02/12/brown-spots/ http://blog.medicalandskinspa.com/2009/02/12/brown-spots/#comments Fri, 13 Feb 2009 01:40:48 +0000 drfoxx http://blog.medicalandskinspa.com/?p=40

BROWN SPOTS

Richard M. Foxx, MD

Perhaps the single most common question I get from patients concerns brown spots. They seem to plague everyone, particularly here in SoCal. And the problem definitely increases with advancing years.

Brown spots, also known as lentigenes, liver spots, or melasma, arise when the pigment called melanin is deposited in melanocytes, or pigment carrying cells, in the dermis. We see it most often in response to long-standing sun exposure, but it may be made worse by certain environmental factors and hormone challenges such as pregnancy or contraceptive pills.

The treatment of brown spots at our office runs the gamut from a series of exfoliative skin treatments and the use of pigment-blocking products to state-of-the-art minimal-downtime laser treatments. Improvement can be achieved over a three to four month period with a series of dermal planing skin treatments which mechanically lighten the spots followed by daily use of a skin product containing hydroquinone. Hydroquinone blocks the uptake of the melanin pigment into the cells. It is not a bleach, however, and the entire process takes several months before a result is seen.

Adding pulsed light treatments hastens the process. The dark cells melanocytes preferentially absorb light, break apart, and come to the surface where they flake away. At least three to four treatments are required over three months, however, as the depth of the spots varies.

By far the most effective method at this time is FRAXEL®. Developed about seven years ago by a group at Harvard, FRAXEL works by placing approximately 2000 columns of laser energy, each smaller than a hair, in a square centimeter (about the area of a dime). Twenty percent of the skin is treated at each of four visits with 80 percent left untreated. The amount of untreated skin results in very little downtime.

The columns of skin that are vaporized by the laser are replaced by healthy new skin over the next few weeks and many of the brown spots are removed.

It is important to understand that no brown spots treatment is permanent. Any brown spot treatment program I a long term commitment and must be accompanied by regular facial treatments, the use of good products, topical anti-oxidants such as Vitamin C, and the daily use of a sunscreen with an SPF of at least 30 and UVA blockers such as Zinc, Titanium, Mexoryl®, and Parsol®.

Doctor Foxx is the Founder and Medical Director of The Medical and Skin Spa, a medical skin clinic in Indian Wells, CA, at Hyatt Grand Champions Resort, one of the country’s only resort-based medical spas.  He may be reached at drfoxx@medicalandskinspa.com or at 760-674-4106

Richard M. Foxx, MD

The holidays are upon us. Again. Everyone who has not put away last year’s Christmas decorations raise their hands.

It seems so unfair—just at the time of year you want to look your best, the deadly combination of parties, alcohol, smoke, lack of sleep, travel, and of course stress, combine to make you look dehydrated, puffy-eyed, and blotchy with large pores and wrinkles.

There are a host of things that can be done; first-aid measures that can perk up your looks and get you back into the fray in short order. But a few simple measures taken now, while Christmas is still light years away, can go a long way toward holiday-proofing your look.

Start now to pump up your water intake and your intake of those precious Omega-3’s and Vitamin C. It takes a few weeks to load your tissues and the results will be worth it. You might even be so impressed you’ll continue to take them all year.

Make arrangements now for a good, exfoliating skin treatment that will remove dead cells, bacteria, and oils. Perhaps a non-ablative skin treatment such as 1064 Nd:YAG Laser Genesis with IPL would be just the thing to tune-up your pores and chase some of those brown spots away. A change in product to one that is more hydrating might be just what you need.

And don’t forget some of the new TRUE mineral makeup magic tricks we have.

Stress always seems to increase during the holidays, even if you’re having fun. And stress kicks up the body’s level of cortisol and all those other bad advanced glycation end products that act as fuel for the breakout fires. Make it a mini-goal to carve out a few moments for you out of every day as a stress antidote. Start now, so when the stress really builds, your relief mechanisms will already be in place.

First-aid measures after the fact can be as simple as keeping hydrated while drinking alcohol, getting as much sleep as possible, sleeping on two pillows to decrease puffiness, and applying cool tea bags for five to ten minutes to those puffy undereyes. And since dehydration seems to be such a problem, going to a richer moisturizer, or switching from a gel to a cream is a good trick to remember.

When all seems lost, something we call the “Desert Quench” that combines a no-downtime exfoliation with an infusion of oxygen enriched hyaluronic serum with peptides can restore even the most dehydrated, hungover, challenged, jet-lagged skin in under an hour.

And one more point: Have fun. And make a few good memories to share when you come back in. That’s what it’s all about, isn’t it?

Doctor Foxx is the Founder and Medical Director of The Medical and Skin Spa in Indian Wells, CA, at Hyatt Grand Champions Resort.  He may be reached at drfoxx@medicalandskinspa.com or at 760-674-4106

]]> http://blog.medicalandskinspa.com/2008/11/17/how-to-avoid-that-holiday-skin-hangover/feed/ 3 http://blog.medicalandskinspa.com/2008/10/01/on-aesthetic-medicine-and-life-3/ http://blog.medicalandskinspa.com/2008/10/01/on-aesthetic-medicine-and-life-3/#comments Wed, 01 Oct 2008 22:39:56 +0000 drfoxx http://blog.medicalandskinspa.com/?p=27

PAIN MANAGEMENT

Richard M. Foxx, M.D.

When I was a boy growing up in New Jersey I found myself in the dentist’s chair with some regularity. My dentist was a rather large and intimidating woman, a refugee from Eastern European and with her accent and steel-rimmed glasses I imagined her to have been some kind of interrogator in the Third Reich. Perhaps, I fantasized, she had gotten out just before her camp was liberated, burned her SS uniform, blended into the population, and moved in down the street to terrorize me.

She did not believe in putting her instruments away after they were cleaned and the operatory tables were covered with all manner of stainless steel devices with screws and plates, instruments I would not see again until I watched Jeremy Irons in DEAD RINGERS years later. I was in terror before she began and anesthesia was not in her vocabulary so I was a wreck before she started and I suffered through interminable drilling sessions with white knuckles.

With that kind of experience, when I grew up and became a physician I understood on a very visceral level how important pain relief and a reassuring demeanor were to the totality of being a healer. It’s almost the first issue in our minds when faced with a medical or surgical procedure.

Pain relief has been as important to me in cosmetic and laser medicine as in almost anything else. It’s either the first or second concern patients have. The other is: “Am I going to look like myself after I have the procedure?”

Anything I do on the face, or anywhere for that matter, demands my complete concentration. If my patient is nervous and uncomfortable and unhappy it distracts me and detracts from my patient’s experience and possibly effects the result. So my answer is always the same: “I won’t start until you’re comfortable and I will spend as much time as is necessary to make sure you’re comfortable.” It’s not hype. You can understand now why I feel that way.

It doesn’t always take all the anxiety away, but it goes a long way in that direction.

Doctor Foxx is the Founder and Medical Director of The Medical and Skin Spa in Indian Wells, CA, at Hyatt Grand Champions Resort.  He may be reached at drfoxx@medicalandskinspa.com or at 760-674-4106