As everyone knows, more and more patients are looking to physicians to help them achieve a more youthful appearance. One of the cornerstones of facial rejuvenation is the use of dermal fillers. By selecting and using the correct dermal filling agent, folds can be softened, lines and wrinkles made much less noticeable, and the face sculpted in such a way that the face looks much more youthful. In this newsletter, we will review the most commonly used dermal fillers so that our patients are better informed regarding how these materials are used.

Juvederm and Restylane
Juvederm and Restylane are very similar products containing hyaluronic acid as the filling agent. The hyaluronic acid is produced under controlled laboratory conditions, does not use any animal or human sources, and is chemically identical to the hyaluronic acid found in humans. For this reason, no allergy testing is needed. The hyaluronic acid in Juvederm and Restylane, in addition to acting as a filling agent, has also been shown to stimulate new collagen formation.

Juvederm and Restylane are used to treat mild to moderate lines and wrinkles, improve skin folds, and augment the lips. After injection, Juvederm and Restylane will last for five to six months.

Perlane and Juvederm Ultra Plus
Perlane and Juvederm Ultra Plus are very similar dermal fillers that, like Juvederm and Restylane, also contain hyaluronic acid produced under controlled laboratory conditions without using any animal or human sources. Again, since every human being has hyaluronic acid in his or her skin, no allergy testing is needed prior to using these fillers. The hyaluronic acid gel particles in Perlane and in Juvederm Ultra Plus are larger than the gel particles in Juvederm or in Restylane. This gives these dermal fillers enhanced lifting power, allowing them to easily fill deeper lines, wrinkles, creases, and folds. For this reason, Perlane and Juvederm Ultra Plus are ideal fillers for the correction of moderate to more severe facial wrinkles and folds, with Juvederm and Restylane used for the shallower wrinkles and folds. After their placement in the skin, Perlane and Juvederm Ultra Plus will provide correction for approximately 6 months.

Cosmoderm
Cosmoderm is a dermal filler that contains human collagen. The collagen is grown under controlled laboratory conditions. Because the collagen in Cosmoderm is chemically identical to natural human collagen, no allergy testing is needed prior to use. Cosmoderm is used to soften superficial and mild lines and wrinkles, and to augment the lips. After placement, it will last for three or four months. Cosmoderm is unique in that it is the filler that can be safely placed closest to the skin surface.

Radiesse
Radiesse is composed of microspheres of calcium hydroxylapatite suspended in a gel carrier. Calcium hydroxylapatite is completely biocompatible. Again, since calcium hydroxylapatite is found in every human being, no allergy testing is needed. The calcium hydroxylapatite microspheres serve as a lattice into which new collagen grows. Therefore, Radiesse produces its effect not only by acting as a passive filling agent but also by stimulating production of new collagen. Radiesse is injected deeper in the skin than Juvederm and Restylane, and is most commonly used to treat relatively deeper folds and lines. In addition, Radiesse can be used for facial sculpting to augment the cheekbones or jaw line. After injection, Radiesse will last for approximately one year.

Sculptra
Sculptra is poly-L-lactic acid, a material that has been used in absorbable sutures for years. Because lactic acid is a material found in humans, no allergy testing is needed prior to using Sculptra. Sculptra is injected into the deeper layers of the skin. Following its placement, Sculptra stimulates the production of a patient's own new collagen. It is this new collagen that ultimately produces the improvement in the appearance of the skin that results from Sculptra. Sculptra is used to treat skin creases, wrinkles, depressions, and folds. Generally two or three treatment sessions every four to six weeks are required to obtain the optimum result. After completion of the treatment course, Sculptra results will last for up to two years in most patients. After that, the result can be maintained with minor touch-up treatments.

The currently available filling agents are truly outstanding, with unsurpassed safety and efficacy. When properly used, they provide completely natural appearing facial rejuvenation. Any of our patients who have not tried these fillers before and have an interest in rejuvenating their face are invited to call our office and make an appointment for a cosmetic consultation with either Dr. Amerian or Dr. Anterasian.

We are excited to announce that the next generation Fraxel laser has arrived, and that we are now using the next generation Fraxel laser in our office. The new Fraxel, called the Fraxel 1500, has many advantages over the original Fraxel laser.

• The Fraxel 1500 uses a new type of treatment tip that eliminates the need for blue dye. With this one change, the nuisance problem of having to first apply and then remove the blue dye no longer exists. This eliminates the persisting blue spots that could not be removed after treatment (that were so bothersome to patients), and shortens treatment times by at least thirty minutes.
• The new Fraxel 1500 automatically optimizes the diameter of the laser beam based on the energy setting that is being used. Optimizing the beam size based on the energy setting improves patient comfort significantly.
• The new Fraxel laser is FDA cleared to treat deeper into the skin than the original Fraxel. As a result, treatments with the new Fraxel will produce greater improvement in fine lines, wrinkles, acne scars, and skin texture. This will be of particular benefit in treating upper lip lines and the lines around the eyes (crow's feet lines).
• Like the original Fraxel, the next generation Fraxel has been cleared by the FDA for the treatment of acne scars, pigmented skin lesions, melasma, surgical scars, and periorbital wrinkles.

What is melasma?
Melasma is a skin condition most commonly characterized by the presence of brown irregular patches on the face of a woman. Quite often, both sides of the face are involved symmetrically, with the most common sites of involvement being the cheeks, bridge of nose, forehead, and upper lip.

Melasma is extremely common, and it affects five to six million American women annually. Over 90% of melasma cases occur in women, and it is especially common in darker skinned individuals, particularly Hispanics, Asians, and women of Middle Eastern ancestry.

What causes melasma?
Although the causes of melasma are not completely understood, several factors are known to play a role. Clearly genetics is a factor, as women with a family history of melasma are more likely to develop the condition. Also, hormonal factors play a role, as pregnancy and birth control pills may also cause melasma. In addition, sun exposure is an important contributing factor.

It is believed that melasma results from exposure to the hormones estrogen and progesterone combined with exposure to ultraviolet light from the sun. This results in an over-stimulation of the pigment producing cells in the skin, increased production of melanin pigment, and the characteristic brown patches of melasma.

How is melasma treated?
Several modalities are available to treat melasma. Melasma resulting from pregnancy frequently, but not always, disappears spontaneously over a period of several months after giving birth. If melasma develops after starting birth control pills, it may improve after discontinuing their use. However, melasma that results from the use of birth control pills usually persists even after the pills are stopped.

Melasma treatment always starts conservatively. If at all possible, it is preferable for women undergoing treatment of melasma to discontinue their use of birth control pills. Although melasma can be treated while continuing the use of birth control pills, this is not optimal.

Sunscreens, sun avoidance, and depigmenting creams are three of the mainstays of melasma treatment. The sunscreen must provide both UV-A and UV-B protection. Regardless of how melasma is treated, the treatment will fail if sunlight is not strictly avoided. Prudent measures to avoid sun exposure include hats and other forms of shade combined with the application of a broad-spectrum sunscreen. Sunscreens containing physical blockers, such as titanium dioxide and zinc oxide, are preferred over chemical blockers because of their broader protection.

Topical depigmenting creams should also be used. Hydroquinone is the most commonly used depigmenting agent; it works by decreasing the production of melanin pigment. Some physicians also add tretinoin (retinoic acid) and a steroid to the hydroquinone. The tretinoin acts by increasing cellular turnover, resulting in a quicker response to therapy. Tri-Luma cream conveniently combines hydroquinone, tretinoin, and a steroid in one medication, and is available by prescription. Other medications for melasma include azelaic acid, kojic acid, and peels containing alpha hydroxy acids such as glycolic acid.

Patients who have not responded to conservative treatment can consider laser treatment. The FDA has approved the use of the Fraxel laser for the treatment of melasma. At the Santa Monica Laser and Skincare Center, we have had good success in treating melasma by combining Fraxel laser treatment with hydroquinone, sun avoidance, and the regular use of sunscreen. Generally, an optimal result can be obtained after four or five Fraxel laser treatments given at four to six week intervals.

Melasma treatment is complex and should be managed by a dermatologist. Generally, several months of therapy are required to significantly improve melasma. Any of our patients who believe they may have melasma or who have abnormal pigmentation in their face are invited to make an appointment with Dr. Amerian.