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

Temperatures rarely go below the high 30’s during the night in what passes for winter here in California’s low desert and most times it’s mid 40’s.  It’s a far cry from the near-zero temps and snowy days up in Montana where friends at Horse Prairie Ranch, and everyone else up there for that matter, turn their horses out to fend for themselves once winter sets in.  The animals are hardy, and they’re none the worse for it.

But somehow, when you get out of bed in the morning and go outside with the dog and realize it really is cold, your thoughts turn to the guys out in the pasture so you give up after a few nights like that and begin blanketing them.  It’s more for us than for them but after you do that you don’t feel quite as guilty turning the heat on in the bathroom when you shave.

Horses in pasture are always a little dusty.  Sometimes they are downright dirty.  You brush their coats before saddling them and between brushing and combing manes and tails you don’t often have time to take a close a look at their coats.

It’s a different story when you take the blankets off in the mornings.  Their coats are usually clean.  When I took Macarena’s blanket off the other morning I marveled, as I often do, at the coppery color of her chestnut hair, exactly like a newly-minted penny that gleams in the sun.  Except this time I noticed that her wonderful red-gold color was flecked with some grey hairs.  A lot of them.

I know she’s getting on, coming 19, but to know it on an abstract level and to see it in the concrete are two different things.  I can accept the grey hairs on my head and accept the grey hairs on Sammy’s muzzle but it brought me up short on her.  I’ve had her for about 13 years.  She was, as Rudyard Kipling once wrote about a pony called the Maltese Cat, the pluperfect polo pony.  She elevated my game orders of magnitude better, like a 15 handicap golfer suddenly playing to a five.  She saved my life at least three times, or at least saved me from serious harm.  She and I are telepathic together.

She knows what it means.  She speaks a different language but she knows now that I know, too.  And that’s always been enough between us.

Gotta go…

www.medicalandskinspa.com

Standing in the shade of a 300 year old live oak at the crest of a hill in Buellton this weekend, surrounded by endless rows of Pinot Noir grapevines heavy with ripe fruit, I learned once again what passion is all about.

This time it came in the form of Richard Sanford, perhaps my oldest and very dearest friend.  The not too distant ocean breeze ruffled his hair as he leaned against an ancient oak table, a glass of ruby-colored Pinot Noir in one hand, and talked about what it meant to be a wine maker, that we were about to drink wine that had been pressed from these grapes last year, and the long journey that had taken him to this spiritual place on an extraordinary day.

I first met Richard almost 40 years ago.  We were both sought-after ocean-racing navigators, competitors, but both passionate devotees of an arcane, pre-GPS avocation that was as much art as science.  When time for sailing became a luxury we stayed in distant touch through mutual friends.  I knew that he was following his dream of starting an organic winery north of Santa Barbara and I cheered him on from afar, and cheered louder when President Reagan chose his wines to be served at his first inaugural.

We reconnected almost 25 years ago when my BW, JoAnn, and I began an annual pilgrimage (it always felt that way) to his eponymous winery and watched as it grew and prospered.  Philosophical conflicts with his investors eventually resulted in his leaving Sanford Winery about the same time JoAnn and I opened The Medical and Skin Spa.

His passion for growing grapes in a sustainable, organic environment drove him to start over and to open Alma Rosa Winery in Buellton, CA, with his wife and soulmate, Thekla.  My passion for the art of cosmetic medicine and the support of my soulmate emboldened me.  The parallels of our lives continued.

Being a farmer is a little like going to the roulette table several times a year and betting everything you have on the red.  But as a vegetable farmer you have the possibility of pulling out your crops if they develop disease, or infestations.  As a grower of grapes you are dealing with plants that take at least three years to reach their potential.  You can’t pull them out and start over.  Multiply that by about a thousand if you are an organic grape grower.  No fungicides, no pesticides to fall back on.

With a dedicated staff, working around the clock many days, Richard and Thekla gradually and painstakingly brought Alma Rosa to its present day, richly-deserved award-winning status.  They make extraordinary Chardonnays and a memorable Pinot Gris, true, but their Pinot Noirs are pure magic.

Which brought us to last weekend.  Walking through the pre-harvest vineyards, tasting the grapes from the vine, realizing their flavor is as far from table grapes as a Verdi aria is from rap, having the rich juice cover your hands and drip down your chin, having Richard talk about the fortuitous interaction of grape with mold with grape genetics, you get a rare and precious peek at passion, that extravagant emotion.

And you realize that passion is what propels some of us, the lucky ones, over the bumps, around the potholes, past the disappointments, and beyond the mid-night terrors.

If we are extraordinarily lucky we get to share it with others.

Richard M. Foxx, MD is Founder and Medical Director of The Medical and Skin Spa in Indian Wells, CA, a lover of fine wine, and devoted to passion in his life and his work.  Visit his website at: www.medicalandskinspa.com.

What does cosmetic medicine have to do with horses?

At first blush the answer is “nothing.”  The real answer for me, however, has turned out to be “everything.”

Even though I wasn’t born in a saddle on a ranch, horses have always been part of my life.  When I was about 12 and I could earn some money delivering groceries I rode my bike into the Orange Mountains near where we lived and rented a horse and rode until my money ran out.  “Cowboy” was always the occupation I wrote down first when my teachers asked us what we wanted to be.

Sometimes it takes years for a dream to come true.  The army, residency, and work put this particular dream on hold for decades until about 30 years ago when I decided it was now or never and since then I’ve never looked back.  Horses will forever be a part of my life.

This is not another “Everything I’ve learned I’ve learned from a horse” article.  But I did immerse myself in their world and the approach to life I’ve developed being around horses became a perfect complement to the philosophy I evolved in my spiritual and metaphysical journey that took me from Zen through Tibetan Buddhism and Taoism; the idea that we are all interconnected, the principle of being in the moment, the value of being congruent.

Most of all, I learned the value of being sensitive to non-verbal communication between horse and human, and between human and human.  Ultimately it made me more sensitive to my patients’ unspoken goals.

Horses are huge, imposing, sentient beings that, in spite of our frequent misunderstandings, help us help ourselves as we learn to develop the skills they need from us.  My journey was so transcending I decided to share my findings and the wisdom of my horses with anyone interested.  To facilitate this I’ve begun a program called THE EPONA EXPERIENCE. It will kick off this fall in the desert.

Way back when, when I was about six or so, full of dreams and full of promise, someone took a picture of me on the back of a pony.  My BW found that about twelve years ago and had it framed.  On the back she wrote: “Once a cowboy, always a cowboy.”

Gotta go.

Richard M. Foxx, MD

David Viscott, MD, was an extremely talented psychiatrist who not only operated a successful LA psych practice in the 1980’s and 90’s but also found time to host a radio show. For me he was to Dr. Laura as Chateau Lafitte Rothschild is to Ripple. I listened to him whenever I could, spoke to him on a few precious occasions, and soaked up as much of his interviewing skills as it was possible to soak up from a distance.

In one of his seminars David (as he insisted everyone call him) passed out sticky labels and asked everyone come in the next morning with this sentence completed and written on the label: “My success depends upon…”

I racked my brain. This was about 20 years ago. I was still young enough to think I could make a difference and old enough to think I had all the answers. All I could come up with was: “My success depends upon paying attention.”

Oh, boy. Somehow I had hit a mother lode. I can’t even begin to count the number of times since then that not paying attention has jumped up to bite me, personally and professionally. And every time that happened I thought of that silly sentence.

As the years went by I struggled to internalize those few words and incorporate them into my way of doing things. The occasions when I have failed to pay attention have thankfully become fewer and fewer.

David Viscott passed away in 1996, at age 58.

What started me thinking about this was a comment from a patient not long ago that she liked how much of a meticulous perfectionist I seemed to be. I thanked her, rolled my eyes (to myself, of course), and thought one more time of David.

What does your success depend upon?

Gotta go…

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

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