While Botox can open up the eyes to look more perky, it cannot correct the cross hatching wrinkles under the eyelids. While dermal fillers can prop up the sagging eye bags, they hardly work with festoony lower eyelids. While upper lid surgery can cut out excessive eyelid skin, the remaining skin is still old.

Instead of simply pulling and cutting the eyelid skin, much like pulling and cutting a worn out carpet, rejuvenation of the eyes start with replacing the worn out tissue with a brand new tissue. When this tissue is replaced and renewed, the eyes truly go back in time . . . five, ten or even 15 years younger.

Acne is American's most common disease affecting 60-70% of Americans at some time during their lives. Twenty percent will have severe acne, which results in permanent physical and mental scarring. The Global Alliance to Improve Outcomes in Acne recently recommended that acne be defined as a chronic disease. It is important to understand that acne is an inflammatory condition that can continue to flare and may be characterized by exacerbations and remissions. While antibiotics constitute an integral part of treatment, acne is not an infection (like strep throat) that will clear after a short course of antibiotics. It is an ongoing condition that will require maintenance treatments, like any other chronic disease. There is no single treatment for acne. Treatment consists of various strategies that complement one another - each strategy targets each step of the acne evolution.

Both females and males have acne that extends into adulthood, with females often having a higher prevalence of the disease as well as more severe forms during adulthood. When untreated, acne usually lasts for several years until it spontaneously remits. Some cases continue into the mid-twenties, and there is evidence that the duration of acne may last into middle age for most women.

Because acne may affect self-esteem, self-confidence, poor body image, embarrassment, social withdrawal, anger, preoccupation with acne, frustration, confusion, and limitations in lifestyle leading to considerable distress, aggressive, effective treatment of acne is needed to minimize both physical and psychological burden and improve quality of life. In addition, patients who receive effective treatment report an improved self-image and less social inhibition.

Genetics play a key role in who will get acne. If both parents had acne, 3 of 4 children will have acne. If 1 parent had acne, then 1 of 4 of the children will have acne. However, similar to other genetic conditions, not every family will have the same pattern, with acne sometimes skipping generations. What is inherited is the propensity for increased proliferation of the cells lining the inside of the hair follicle with subsequent plugging of the opening of the hair follicle.

How Does Acne Develop?
Acne arises from the interaction of 4 factors:
1. Excess sebum production caused by androgenic stimulation of oil glands (sebaceous glands);
2. Obstruction of the opening of the hair follicle arising from excess production of keratinocytes (the basic cells of the skin);
3. Increased proliferation of the bacteria P acnes (Propionibacterium acnes) that normally live in the sebaceous follicle; and
4. Inflammation caused by sebum escaping into the surrounding skin.

Sebaceous or oil glands are pouch-like protrusions on the side of the hair follicle. The number of oil glands remains approximately the same throughout life, whereas their size tends to increase with age. Their function is to produce an oily substance called sebum. Sebum normally travels up along the hair shafts and then out through the opening (pore) of the hair follicle onto the surface of your skin, to lubricate and protect hair and skin. Acne affects the areas of skin with the densest population of hair follicles; these areas include the face, the upper part of the chest, and the back.

Oil production is known to spike twice in life. The first spike occurs a few hours after birth - which peaks during the first week and slowly subsides thereafter. Pimples in newborns are not infected and they eventually subside without treatment. The second spike takes place at about age 9 years old, just before puberty. During this period, the adrenal glands produce large amount of androgen hormones that continue into early adulthood. Clinically, there are obvious changes happening in boys and girls during this time. Hair in the armpits as well as hair in the private areas start to appear associated with adult body odor. The skin that was once soft becomes thicker and oilier. There is a clear association between increase oil production and acne. The two spikes in oil production bring about the lesions seen in acne, except that in newborns, the lesions are not due to an acne bacteria and therefore it is not an infection. On the other hand, the acne lesions that occur during the second spike are typically associated with acne bacteria, and therefore, treatment is needed.

The increased oil production before puberty is also accompanied by an increased proliferation of hair follicle cells, called keratinocytes. Oil and keratinocytes stick together and build up within the pore and form a soft plug giving rise to the small pimple, the precursor of all acne lesions. While the pore opening remains closed, the lesion is called a closed comedo, or "whitehead". The closed comedo is 1-3 mm in diameter, white or flesh-colored, and very slightly raised. Oxidization occurs when the pore enlarges enough to stretch the plug and the trapped matter is exposed to air. This causes the characteristic dark appearance of open comedones or "blackheads." Open comedones are flat or slightly raised, brown-to-black papules about 3-5 mm in diameter.

P acnes bacteria is a harmless, normal inhabitant of a healthy, human skin. It lives in the hair follicle and survives by feeding from the oil produced by the oil glands. When a pore is blocked, P acnes overgrows. As the trapped oil and keratinocytes continue to pile up, the pore balloons out and gets deformed, now called a cyst. Meanwhile, the irritating acids produced by P acnes damage the cyst wall. As damage and continuing distention of the cyst occur, the cyst wall ruptures and release hair, oil, dead cells and irritating acids into the surrounding dermis. When the cyst is intact, the damage is localized only to the hair follicle. When the cyst ruptures, the damage becomes greater. The leakage of the cyst contents into the dermis incites an inflammatory reaction and initiates the formation of the various types of acne lesions: papules, pustules and nodules.

Acne papules are pink or red and 2-5 mm in diameter. Acne pustules are pink or red with a yellow center because of the pus inside. Acne nodules are solid, 6-10 mm in diameter, painful cysts situated deeper in the dermis. The acne cyst is a large nodule that has suppurated and become fluctuant. Scars form as a result of damage to the surrounding dermis.

Acne is a continuous process and causes the eruption of new lesions over time, so at one time there may be comedones, papules, and pustules. Acne is usually described by the primary lesions present and the severity of those lesions (mild, moderate, or severe). Comedonal acne is the presence of a predominance of open and closed comedones. Mild comedonal acne would have only a few open and closed comedones. Severe comedonal acne would have many comedones, but only a few papules and pustules. Inflammatory acne is the presence of erythematous papules and pustules. Cystic acne is characterized by multiple cysts, nodules, and pitted scarring.

Acne keloidalis: Individuals who have the genetic predisposition to have a keloid reaction to inflammation will develop keloids in the beard area, along the jaw line, and on the back of the scalp.

Acne conglobata: Acne conglobata is an uncommon and unusually severe form of acne characterized by large deep nodules, cysts, and abscesses that coalesce together and connect with one another often producing pronounced disfigurement. The lesions are usually found on the chest, the shoulders, the back, the buttocks, the upper arms, the thighs, and the face.

Post-Inflammatory Hyperpigmentation (PIH): In darker-pigmented skin, inflammation will cause increased production of melanin. As acute acne lesions fade, they leave dark spots that are as cosmetically distressing as the acne itself. Skin discoloration becomes worse with sun exposure, so an effective sunscreen should be used twice daily, in the morning and early afternoon.

The treatment of acne is aimed at preventing scars from forming. Because treatment is preventive, not curative, improvement may be slow.

Targets of acne treatments include:
1. Reduce oil production,
2. Normalize keratinocyte turnover in the follicle
3. Speed up sloughing of dead skin to keep the pore open
4. Fight bacterial infection
5. Reduce inflammation

Over the counter and prescription products perform one or all of the above targets in varying degrees. Over the counter products typically contain benzoyl peroxide, sulfur, resorcinol, salicylic acid or lactic acid as their active ingredient. These products can be helpful for very mild acne. Prescription products typically contain more potent ingredients such as tretinoin and antibiotics.

The most common and expected side effects of acne treatment are related to its targets: skin irritation, dryness, flaking, stinging, burning, redness or peeling. Excessive dryness can cause oil production to rebound. Bioactive moisturizers can help prevent dryness.

Topical retinoids constitute the cornerstone of acne therapy, as they not only help resolve existing breakouts but also prevent the development of recurrences. Tretinoin makes keratinocytes in lining the pore less adherent and easier to remove.

Oral contraceptives have been shown to be useful in managing female acne since 1951. After 3 months of therapy with oral contraceptives, sebum production can be decreased by as much as 40%.

Laser and light therapy. Laser- and light-based therapies reach the deeper layers of skin without harming the skin's surface. Laser treatment is thought to damage the oil glands, causing them to produce less oil. Light therapy targets the bacteria that cause acne inflammation. These therapies can also improve skin texture and lessen the appearance of scars.

Chemical peels and Microdermabrasion may be helpful in controlling acne. These cosmetic procedures — which have traditionally been used to lessen the appearance of fine lines, sun damage and minor facial scars — are most effective when used in combination with other acne treatments. They may cause temporary, severe redness, scaling and blistering, and long-term discoloration of the skin. Microdermabrasion assists in enhancing the absorption of topical treatment.

Isotretinoin (Accutane): Isotretinoin is a form of vitamin A. It decreases the size of the oil glands, thus decreasing the amount of oil produced. When appropriately used, it is very effective in achieving long-term remission of acne. It is usually given after other acne medicines or antibiotics have been tried without successful treatment of symptoms. Isotretinoin is available only under a special program called iPLEDGE.

The following are not treatments:
• "Picking" or "popping" pimples will increase inflammation and worsen scarring.
• Abrasive cleansers or sponges should be avoided because they cause microscopic abrasions and create portals for the entry of bacteria.
• Astringents containing alcohol will dry and irritate the skin further and cause oil production to rebound.
• Mineral oil-based products in cosmetics, sunscreens, hairstyling products or acne concealers can add to the pore plug and worsen acne.

Acne scars represent an entirely different, highly challenging frustrating clinical problem. In essence the issue involves surface and subsurface scar tissue rather than normal anatomy. This is further complicated by the three-dimensional face on which light and shadow interact such that shallow and relatively minimal scars may at times appear harsh and objectionable. The scar surface often has overlying dispigmented skin so that the improvement in the scar may appear clinically suboptimal because of residual color anomalies.

In mature forties or fifties skin, acne scars may appear worse. The scars are more visible as a result of facial volume loss and or decreased skin turgor or loss of elasticity. As facial skin begins to droop from aging, the skin becomes irregularly suspended from fibrotic areas of scar , creating an uneven rolling appearance with step like drop offs.

Checking if the scar is distensible is a crucial point. If the adjacent skin on opposite sides of the scar is stretched and the scar flattens, then the scar is much more amenable to various treatment options. If the scar is bound down and doesn't flatten or smooth out with stretching, then the scar is substantially more resistant to any therapeutic modality. Ice pick scars are non-distensible because they are usually deeper than they are wide. The description comes from the concept of a sharply demarcated ice pick hole in ice. Typically the surrounding tissue of ice pick scars is firm and cicatricial.

Acne scars may also appear as box car scars or sloping depressions that look like rolling hills and valleys. There are numerous procedures that can be used to correct acne scars. There is no single approach that stands out as the most effective. Choices are dictated by the type of scars, age issues, skin color, financial considerations, procedural risk, and upon the patient's acceptance of any available options. Each procedure has its own risks and benefits, and several procedures are normally combined to create the smoothest appearing skin.

Dermabrasion
Dermabrasion with a motorized diamond wheel or needle brush called dermaroller was the standard of care prior to lasers. This invasive procedure is highly effective but hypo pigmentation is common. General anesthesia is performed and the dermaroller is rolled over the skin, creating wounds that the body repairs with new skin.

Laser Resurfacing
Laser Resurfacing works by essentially vaporizing the top layers of the skin to a precise depth of the surgeon's choosing. The skin then heals replacing the vaporized layers with newer appearing skin. Because the potential for hyperpigmentation is increased in darker skin, this procedure is typically perfomed on fair skin.

ProFractional Resurfacing
While laser resurfacing vaporizes 100% of the skin, ProFractional resurfacing vaporizes only fractions of the skin. This procedure leaves bridges of intact skin in-between the vaporized skin. Similar to laser resurfacing, the vaporized skin is replaced by new skin. This procedure can be perforned on ethnic or darker skin.

The advantage of laser resurfacing over ProFractional resurfacing is that it can potentially eliminate shallower acne scars in one treatment. The disadvantage is prolonged downtime.

The advantage of ProFractional resurfacing is its ability to go after deeper acne scars with minimal downtime. The disadvantage is the need for multiple treatments.

While the results are not 100% fix, acne scars can be dramatically improved by laser treatments. Laser can smooth the edges of the scars, make the acne pits cast less harsh shadows and many of the scars can be completely erased (though some will remain).

Dermal Fillers
There are many types of dermal fillers that can be injected into acne scars to raise the surface of the skin and give a smoother look. Subcision is necessary to place any filler under a tight scar. The injection of these materials does not permanently correct acne scars, so further injections are necessary.

Fat Fillers
Fat is harvested from one area of the body and injected into the acne scars. Subcision is necessary to place fat under a tight scar. Results can last as long as three years.

Punch Excision
Used on deep icepick and deep boxcar scars, this procedure uses a punch biopsy tool which is basically a round, sharp "cookie-cutter" tool that comes in diameters ranging from 1.5 mm to 3.5 mm. The size of the tool is matched to the size of the scar to include the walls of the scar. Under local anesthesia the scar is excised with the punch tool and the skin edges are sutured together. The newly produced scar eventually fades and may not be noticeable. If it is noticeable, it is now more amenable to resurfacing techniques.

Punch Elevation
This method of surgically correcting acne scars is used on deep boxcar scars that have sharp edges and normal appearing bases. The same punch tool as above is used to excise the base of the scar leaving the walls of the scar intact. The excised base is then elevated to the surface of the skin and attached with sutures, steri-strips, or skin glue called Dermabond.

Subcision
Subcision is simple, minimally invasive, and is integral to successful filler treatment of acne scars by establishing a space for injecton of dermal fillers or fat. Since many acne scars are bound down, injecting dermal fillers or fat directly under or into the scar without prior subsicion can result in extrusion of the filling substance into the non scar surrounding tissue, and the end result is an elevated donut of filler substance around the scar.

Under local anesthesia, a specially beveled needle is inserted horizontally or at a slight angle adjacent to the scar. The needle is moved back and forth horizontally under the scar in a fanning configuration such that the entire cicatrix binding the scar is released. The depth of the subcision is based on the cicatrix underlying the scar.

Brown Spots and Melasma are skin pigmentation disorders that affect the color of the skin. Pigmentation means coloring. Skin has outer and inner layers. The outer layer that is exposed to the environmental elements is called epidermis. Because the epidermis is exposed, it replaces itself constantly, which is about every 47-48 days.

The inner protected layer is called dermis and contains the hair follicles, oil glands, blood vessels, and collagen. A thin sheet of fibers, like a plastic liner, called basement membrane, separates the epidermis from the dermis. Cells called melanocytes are located at the most bottom part of the epidermis above the basement membrane as well as in the portion of the hair bulb. Melanocytes produce melanin - the dark pigment that imparts color to the skin.

Skin color is innately determined by the density and distribution of melanin in the skin, which is controlled by the activity of the enzyme tyrosinase. Under the direction of tyrosinase, melanocytes produce melanin. Melanin pigments are packaged in packets called melanosomes and leave the melanocytes to get inserted into the neighboring epidermal cells called keratinocytes. Once inside the keratinocyte, the melanosomes are spread above the DNA-containing nucleus. When exposed to ultraviolet (UV) radiation in sunlight, the melanin absorbs the damaging light and the DNA-containing nucleus is spared. If there are no melanosomes to cover the nucleus, the DNA can mutate and produce cancer cells. This is the reason why skin cancer affects more fair skin individuals. They have less melanin to protect them. Afterwards, the keratinocytes rise to the top layer of the epidermis and die. Eventually they are desquamated. The whole process is again repeated.

While melanin is considered a natural sunscreen, it is best to wear a chemical sunscreen so that the damaging light is stopped at the top most epidermal layer and less chance of getting deeper into the DNA-containing cells. When melanocytes become damaged or unhealthy, it affects melanin production. If melanocytes produce too much melanin, skin gets darker. If they produce too little melanin, skin gets lighter. Some pigmentation disorders affect just patches of skin. Others affect the entire body. There are no significant differences in the number of melanocytes in different skin types or among individuals of different racial and ethnic backgrounds. The differences in skin color are attributed to the varying degrees of activity of the enzyme tyrosinase in melanosomes, variations in melanosome number, size and groupings of the melanosomes, and the efficiency of melanosome transfer to the keratinocytes. A key characteristic of skin of color is the tendency for melanocytes to exhibit labile responses to inflammation and injury, which is why pigmentation disorders in this population is more widespread. Sun exposure and pregnancy can make skin darker. Sun exposure is the single most important precipitator of skin pigmentation.

The three most common pigmentation problems presented to this office are:
• Post-Inflammatory Hyperpigmentation (PIH)
• Melasma
• Freckles

Post-Inflammatory Hyperpigmentation (PIH)
Post-inflammatory hyperpigmentation (PIH) refers to increased pigmentation of the skin after (post means after) an inflammatory condition in the skin has subsided. They appear as well-demarcated patches of darker skin color, usually referred to as blemishes. Excess pigment can be deposited in both the epidermis and dermis or just the epidermis alone. When the dermis is involved, there is disruption of the basement membrane. The opening created by the disruption causes some of the melanosomes to fall into the dermis and get engulfed by special cells called macrophages. Dermis does not replace itself like the epidermis so that the duration of the hyperpigmentation is prolonged and can last several months to years. Because the epidermis replaces itself every 47 - 48 days, hyperpigmentation is more amenable to treatments.

PIH associated with acne is very common. In acne infection, not only the basement membrane is disrupted, the entire hair follicular unit is destroyed causing massive damage and eventual falling of the melanosomes into the dermis. The damaged skin is exposed to the outside environment triggering an increased melanin production. An unusually large amount of melanosomes are dispatched into the site for protection. Hence, the clinical picture of dark spots which at times is more frustrating than the acne itself.

The following principles guide the treatment of PIH:
1. Sun avoidance
2. Reduce melanin production
3. Reduce the transfer of melanosomes to the keratinocytes
4. Enhance sloughing or shedding of pigment containing keratinocytes
5. Treat any inflammatory condition of the skin.

Sun avoidance is obvious. Without the damaging light, there will be no reason for the melanocytes to produce more melanin.

Melanin production is effectively reduced by Hydroquinone - which has been first-line therapy for hyperpigmentation for close to 50 years. It blocks the activity of the enzyme tyrosinase and suppresses melanocyte metabolic processes. Other lesser potent products that reduce melanin production as well as reduce melanosome transfer: arbutin, licorice, azelaic acid, kojic acid, aleosin, linoleic acid (omega-3 fatty acid), glabridin/liquitrin (licorice extract), soy, N-acetylglucosamine, niacinamide, vitamin C, oligopeptide and N-undecyl-10-enoyl-L-phenylalanine. Exposure to sunlight or UV light causes repigmentation, which may be prevented by the broad-spectrum sunscreens.

Topical retinoids have been shown in multiple studies to be effective in the treatment of PIH. Proposed mechanisms by which topical retinoids improve hyperpigmentation include: inhibition of tyrosinase induction in melanocytes; enhancement of desquamation that speed up sloughing of melanin in keratinocytes; inhibition of melanosome transfer from melanocytes to keratinocytes; and redistribution or dispersion of epidermal melanin.

Microdermabrasion assists in enhancing the absorption of topical treatment. A chemical peel may help in about one third of the cases, one third of cases remain the same, and another one third of cases show worse hyperpigmentation.

Because the development of PIH is directly related to the inflammatory process that preceded it, it makes sense to immediately treat any skin condition such as acne so that inflammation can be prevented.

Melasma
Melasma is another pigment disorder more common in Black, Hispanic and Asian individuals. It is characterized by irregular light-brown to gray-brown patches more often on the face, including the cheeks, nose and forehead regions, but also seen on the chest and arms. Melasma is much more common in women than in men.

The mechanism by which melasma develops is uncertain that makes it impossible to treat permanently. In many cases, a direct relationship with female hormonal activity appears to be present because melasma occurs with pregnancy and with the use of oral contraceptive pills. Other factors implicated in the development of melasma are photosensitizing medications, mild ovarian or thyroid dysfunction, and certain cosmetics. More than 30% of patients have a family history of melasma.

A genetic predisposition is a major factor in the development of melasma which can be triggered by pregnancy, oral contraceptives, allergenic products, intense heat and sun exposure. Sun exposure is the most important trigger such that the pigmentation becomes darker during the summer and lightens up in the winter months. Without strict sun avoidance, melasma treatment will fail.

Melasma can be difficult to treat. The pigment of melasma develops gradually, and resolution is also gradual. Resistant cases or recurrences of melasma occur often and are certain if strict avoidance of sunlight is not rigidly heeded. All wavelengths of sunlight, including the visible spectrum, are capable of inducing melasma. While treatment is not permanent, melasma can be succesfully controlled. Similar to PIH, the epidermal pigments are easier to manage than the dermal pigments. Dermal pigment may take longer to resolve than epidermal pigment because the dermis does regenerate like the epidermis. Trapped pigments are stuck in here for a long time. Dermal pigments are fallen epidermal pigments. If production of epidermal pigments can be blocked for long periods, the dermal pigment will not replenish and will slowly resolve.

The following principles guide the treatment of PIH:
1. Avoid triggers (especially estrogen) and sun avoidance.
2. Reduce melanin production
3. Reduce the transfer of melanosomes to the keratinocytes
4. Enhance sloughing or shedding of pigment containing keratinocytes
5. Reduce dermal pigments

As with PIH, principles 1, 2, 3 and 4 apply to melasma treatment, except that avoiding triggers apply only on melasma. Chemical peels are not normally used as treatment for melasma in this office because the potential to make melasma worse is higher than making it better.

Dermal pigments can be reduced by ablative fractional resurfacing with an Erbium Yag. Multiple columns of laser beams are drilled into the skin and pull out fractions of the skin that includes the dermal pigments. While this is not a 100% cure, the skin repairs itself with new skin without the pigments. This procedure shortens the waiting time for melasma to lighten up. Erbium Yag does not produce the collateral damage seen with CO2 laser.

Freckles
Freckles (Ephelides) are tanned non-elevated patches found on the skin. Freckles are usually multiple in number. Although freckles are predominantly harmless, they may be seen in association with an internal illness. Freckles are usually associated with fair skin and red or blonde hair. In contrast to sun-induced brown spots found in adults, freckles are not strongly associated with age. They are frequently seen in young children.

Heredity may play in people developing freckles. The melanin-containing packets become bloated or enlarged as the skin gets exposed to the A and B ultraviolet components of the sunlight. The bloated or enlarged melanin-containing packets produce the clinical picture of freckles. Think of Lindsay Lohan and Julianne Moore.

Principles of treatment for freckles are similar to PIH but chemical peels, broad band light therapy and microlaser resurfacing do the best job in clearing them out.

Exclusively developed by Dr. Cynthia Lopez, this treatment combines the collagen tightening of LaserTyte-1320 with Profractional resurfacing. This treatment is especially effective for stretch marks as well as loose, sun-damaged facial skin.

Wrinkles represent one of the symptoms of aging. They appeared because the underlying structures also have aged: the fat pads and muscles shriveled and the bony structure holding all that soft tissue also shriveled giving the old look: collapsed or deflated face with loose skin hanging over the bony prominences. If you think of the face as a table and a tablecloth, where the bony support is the table and the soft tissue (in terms of fat and muscle and the skin that wraps around the whole thing) is the tablecloth, with no support underneath that soft tissue, it's going to begin to fold and sag.

The changes in aging occurs interdependently between tissues. Although the sequence of those changes is somewhat predictable, the pace of those changes is very individual between different patients and even between tissue layers within the same individual. Those changes lead to the morphologic changes that we see in the aging face, in terms of the topography of the face and how it reflects or shadows light, and in terms of the shape, the balance, and the proportions of the face.

There is no single aesthetic tool that can address the myriad presentations of aging and associated pathologies. Combination therapy that includes Botox, dermal fillers, fat fillers, chemical resurfacing, lasers and energy devices, and surgery provide optimum efficacy and is considered the foundation of contemporary aesthetic treatment. Combined modalities provide aesthetic effects beyond what could be achieved with each alone.

The primary impetus toward combination therapy is the evolution of the approach to facial rejuvenation from a 2-dimensional viewpoint of lines and wrinkles to a 3-dimensional perspective on facial aging. The 2-dimensional approach involves lifting and pulling (surgical face lift) that produces an unnaturally looking face. The 3-dimensional approach requires an understanding of the multi-factorial etiology of aging, including the many intrinsic and extrinsic factors that combine to create patients' unique presentations. As eloquently stated by Kenneth Beer, "Each patient looks old for their own reasons and in their own way." Taken a step further, patients will require a similarly unique approach to correcting those signs of aging.

Aging is now approached in terms of volume loss and facial deflation. As the face falls downwards, it also sinks inwards. When this happens, the long smooth sweeping curves that are present in a youthful face are lost. The long sweeping curves are present in the brows down to the upper lids, down to the cheeks and along the jaw line. With aging, these long smooth curves are replaced by hills and valleys that create the old look. Facial rejuvenation is no longer viewed as simple wrinkle eradication but rather volume restoration to recreate the smooth facial curves of youth.

A thorough assessment lays the foundation for designing a treatment plan that optimizes results. Prior to treatment, an assessment is made on patient's lines and wrinkles, muscle anatomy and movement; the degree and location of volume loss; skin texture and elasticity; the degree of photodamage and dyspigmentation; and any skeletal changes such as bone resorption. The findings will inform the treatment approach. For example, Botox injections are widely acknowledged as a superior treatment for softening the lines and wrinkles associated with muscle action. They cannot, however, reestablish volume or address skin pigmentation changes.

What is LaserTyte-1320™?
• LaserTyte-1320 is non-invasive facelift (No scarring. No swelling)
• LaserTyte-1320 restores youthful contours (No nipping or tucking. No unnatural results)
• LaserTyte-1320 stimulates natural collagen growth (No foreign chemicals. No implants)

LaserTyte-1320 is a revolutionary laser treatment pioneered by Dr. Hogue at Hogue Cosmetic Surgery in Maple Grove, MN which uses an FDA cleared laser to tighten the skin and dermis. An infrared laser technology is used to deliver laser energy through the skin to deeply heat the dermal collagen resulting in shrinkage of dermal tissues including skin, oil glands, skin pores, and dermal blood vessels. The existing collagen fibers in the dermis immediately tighten and undergo contraction. Subsequently, this stimulates new collagen growth that is responsible for skin elasticity.

LaserTyte can do a lot on the face and neck. It affects the deep dermis and achieves enhanced skin tightening, resulting in eyebrow elevation, wrinkle reduction, and contouring of the lower face and jowls. In my opinion, it is the best thing there is short of a face lift.

Is there a downtime to this procedure?
This procedure is non-invasive. Without damaging the outer layers of the skin, it is a great for people who wants to resume all their activities as soon as the procedure is done.

Is the procedure painful?
LaserTyte is well tolerated. The procedure is not painful, so there is no need for any numbing cream at all. As the infrared laser is passed back and forth into the skin, building up the desired heat, the skin will feel very, very warm. Once in a while, there will be a hot spot, but it should not be painful.

Is one treatment enough?
Something will be evident after the first treatment. Skin is more lifted and tighter. Wrinkles are shallower. The optimal number of treatments to start is three treatments one month apart. Each treatment builds synergistically from the first. Three treatments will have more new collagen than two treatments than one treatment. Thereafter, repeat treatments are recommended every 6 to 12 months.

What immediate effect is expected?
There will be an immediate firmness, tightness, mild pinkness, and shallowing of wrinkles.

How long does the effect of LaserTyte last?
Even with one treatment, LaserTyte not only produces tightening, but it also enables the skin to put new collagen in the bank which is a permanent improvement. While the skin may not be permanently tighter, the new collagen is permanently present. The question really is, how long will the new collagen in the bank last? It all depends on how the skin is taken cared of from the point of treatment. The newly deposited collagen will be subjected to the same aging elements that have affected the skin since birth, which accumulates over time. As long as strict sun avoidance, no smoking, and healthy lifestyle are followed, this new collagen should last as long as it is protected.

What areas can be treated?
LaserTyte treatments are safe for all skin colors and can be performed on any area of the body where skin rejuvenation and skin firmness is desired. Popular treatment areas in our office include the face, neck, décolleté, abdomen, and arms but would work in any area where tightening is desired.

Who is a good candidate for LaserTyte-1320™?
Sagging skin due to laxity and not sagging skin due to excess fat. As a general rule, thin skin without underlying excess fat can be treated most effectively. After baby abdomen of young mothers respond well to LaserTyte.

Since birth, collagen is constantly being remodeled in the skin. As the human being passes through aging, sun exposure and smoking, more collagen is being broken down than built. This is the reason why older people responds less than younger people. However, even if the older people don't see the 2 to 3 millimeters of lifting, they feel their skin is firmer and springier.

Who is not a good candidate for LaserTyte-1320™?
• Skin that sagged due to excess fat. Even if LaserTyte improves the skin, the result will not be visible because of the underlying pressure from the fat.
• Smoker. The vasculature of a smoker is compromised and new collagen deposition may also be likely compromised.
• Patients who firmly place their hands on their face and pull back towards their ears are not evaluating themselves for a LaserTyte. They are evaluating themselves for a surgical face lift. While LaserTyte contracts the dermis back into place and creates a spandex-like support effect, it does not alter the underlying structure below the dermis. Therefore, while it can delay the need for surgery, it does not replace a face lift or liposuction.

Developed by Dr. Todd Bessinger in Hawaii, this is also available to patients of Dr. Cynthia Lopez. This is a combination of the ProFractional Resurfacing and BBL procedures. It is especially effective at reversing aged and sun-damaged skin and can safely be used on the face, arms, legs, and chest and for nearly all skin colors and tones.

We have the only tunable laser resurfacing system in the Central Valley that treats acne scars, stretch marks, and rejuvenates sun-damaged, wrinkled skin. It strips away 100% of the surface of the skin to a specific depth that can be shallow or deep or in-between.

We have the only ProFractional fractionated resurfacing laser in the Central Valley that effectively treats acne scars, wrinkled skin and stretch marks without the downtime of traditional lasers. Compared to other fractionated resurfacing devices like the Fraxel, the ProFractional is surprisingly comfortable and patients have less downtime and fewer overall treatments.

ProFractional works similar to aerating a lawn. When the lawn is aerated, lots of small holes are created in the lawn. With ProFractional, lots of small holes are created within the skin -- holes of injury, so to speak. Those holes, however, are separated by normal skin, which allows the skin to recover faster.

Exclusively developed by Dr. Cynthia Lopez, this is a highly effective treatment for wrinkles, loose skin, jowls, and double chin without surgery. It works by employing the three best tightening technologies available in the market: LaserTyte 1320, Prolift 1064, and Tunable Laser Resurfacing.

With all their money, even Madonna and Cher have wrinkly skin. Exclusively developed by Dr. Cynthia Lopez primarily to treat her own hands, this treatment is now available to her patients. The procedure combines the collagen tightening of LaserTyte-1320, the aerating ability of ProFractional resurfacing, the ability of BBL to remove sun spots, and the volume restoration of dermal fillers.

While rosacea cannot be cured, it can be controlled. Rosacea, sometimes referred to as the "Curse of the Celts", usually occurs in adults with fair skin, especially those of Northern and Eastern European heritage. They also occur in skin of color though not as widespread. It is a common skin disorder affecting middle-aged and older adults. Many patients mistakenly assume that early rosacea is normally aging skin and are not aware that effective treatments exist to prevent progression to permanent disfiguring skin changes.

As the general population ages and the baby boomers increasingly dominate clinical practice, a frequent complaint is the red face. Of the many causes of the red face, rosacea will be the diagnosis for approximately 13 million Americans. Although not a life-threatening condition, rosacea produces conspicuous facial redness and blemishes that can have a deep impact on a patient's self-esteem and quality of life.

Rosacea develops gradually. Many patients, unaware that they suffer from a treatable skin condition, assume that the intermittent facial flushing, small bumps, and small pus-filled cysts are adult acne, sun or wind burn, or normal effects of aging. Correct diagnosis and early treatment of rosacea are important because, if left untreated, rosacea can progress to irreversible disfigurement and vision loss. Rosacea is a disorder of the blood vessel with distinct, predictable symptoms that follows a remarkably predictable course. Rosacea generally involves the cheeks, nose, chin, and forehead, with a predilection for the nose in men.

There are four acknowledged general stages of rosacea:
• Stage I is pre-rosacea. This stage is characterized by frequent blushing, especially in those who have a family history of rosacea. Blushing as a symptom of rosacea can start in childhood, although the typical age of onset for rosacea is 30 to 60 years. There might be increased frequency of facial flushing or complaints of burning, redness, and stinging when using common skin care products or anti-acne therapies.
• Stage II. At this point in the disease progression, redness of the middle part of the face and the presence of bloated capillaries become apparent.
• Stage III. The facial redness becomes deeper and permanent and the bloated capillaries become more apparent. Crops of bumps and pus-filled cysts, commonly mistaken as acne, begin to develop. The eyes start to become red and swollen too.
• Stage IV. Skin and eye changes rage on. Inflammation of the eyes can progress to keratitis (inflammation of the cornea) and result in loss of vision. Multiple bloated and broken capillaries are now mostly concentrated in the mid-face. It is at this point that fibroplasia (diffused, non-orderly expansion of connective tissue within the dermis) and enlargement of the oil glands of the hair follicles produce the nasal enlargement known as rhinophyma (a bulbous enlargement of the more).

Recently, a standard classification system of rosacea was developed by the National Rosacea Society to clarify and facilitate communication for treatment regarding this disease.
1. erythematotelangiectatic
2. papulopustular
3. hymatous and
4.ocular

Subtyping is useful in designing a treatment plan for patients. Some patients with these subtypes respond well to topical and oral treatments, whereas others may see no relief at all with the available medications and may respond better with light and laser treatments.

Triggers of Rosacea are:
• Weather: sun exposure, extreme temperatures – hot or cold, humidity, harsh wind.
• Emotional influences: : anger, anxiety, embarrassment, stress.
• Temperature –related activities: saunas, hot baths, heated work environments (e.g. factories, kitchens).
• Physical exertion: exercise, "lift and load" jobs.
• Beverages: alcohol, especially red wine, beer, bourbon, gin, vodka, champagne; hot drinks, including hot cider, hot chocolate, coffee, tea.
• Foods: hot and spicy foods; dairy products, including yogurt, sour cream, some cheeses; chocolate, vanilla, soy sauce, vinegars; vegetables, including eggplant, tomatoes, spinach, lima, and navy beans, peas; fruits, including avocados, bananas, red plums, raisins, figs, citrus fruits.
• Medications: topical fluorinated corticosteroids; vasodilators, nicotinic acid; ACE inhibitors, calcium channel blockers; cholesterol-lowering statins.
• Topical skin care products: cosmetics and hair sprays that contain alcohol, witch hazel, acetone, fragrances, soaps, astringents.

Rosacea Treatment:
• Avoid triggers
• Antibiotics: Topical and Oral
• Tretinoin (Retin A)
• BBLTM Broadband Light

Fillers are injected substances that lift the skin and can correct deeper wrinkles or elevate sunken areas and some scars. There are many types of fillers and although they are not permanent, many last for several months. Dr. Cynthia Lopez uses Radiesse and Juvederm. These two are ideally used in combination to achieve better sculpting resuts. For patients who have can afford to wait, adding Sculptra, a collagen replacer can make the results more natural-looking. Results can range from 5 months to three years.

Botox works by blocking the communication between the nerve and the muscle that temporarily paralyzes muscle that pull on the skin causing the wrinkles. After injection, Botox begins working approximately 72 hours later. The art of injecting is to achieve relaxation of the wrinkles without giving a "mask-like" look to the patient. The effects generally last about 3 months.

Botox is also used successfully to treat migraine, severe sweating of the armpits, hands, and/or feet called hyperhidrosis.

Warts are removed by using Surgitron high frequency radiowave technology, laser resurfacing or surgical excision.

We use two types of light source for dramatically reducing hair: Laser and BBL™ Broadband Light. Laser is used during the first two treatments when the hair follicles are darker and bigger. As they become lighter and finer, BBL™ Broadband Light is used. This technique provides better outcomes in permanent hair reduction.

Better than the PinPointe Laser, the Sciton laser used in our office is FDA approved and the same laser used by Stanford Medical Center. While no treatment for nail fungus is 100% guaranteed, the Sciton laser has produced successful results in 75-80% of cases in clinical studies. That success rate is roughly the same as oral medication and much better than anything that can be applied to the nails. A major advantage of using the laser is that you are able to get the curing power of oral medication without any side effects. The Sciton nail fungus laser is safe, non-toxic and effective.

Q: What causes nail fungus infection?
A: Onchomycosis refers to a fungal infection that affects the toenails or the fingernails. It is caused by a dermatophyte - the type of fungus that usually infect the dead cells of the human's outer coat: nails, hair and top skin. The fungus has the ability to feed from these dead cells. Fortunately, it does not have the ability to go pass the dead cells to infect the living cells below.

Q: How do you get fungal infection?
A: Minor skin or nail injuries, moist skin for a long time, closed footwear (because it can trap moisture). Athlete's foot often precedes toenail infection.

Q: How does the laser kill the fungus?
A: The laser works by creating heat in the nail and nail root. The heat kills the fungus so it cannot multiply.

Q: What does the laser treatment consist of?
A: There are three parts to the treatment program: preparation, laser treatment and follow-up. Preparation includes an exam, an explanation of the treatment by the doctor and sending a piece of nail to the lab to be sure there is actually fungus present. Laser treatment itself takes about 30 minutes in the doctor's office and requires no injections, bandages or medication. Usually, only one treatment is necessary. Follow-up includes sending a second nail specimen to the lab three months after the laser treatment (to be sure the fungus is completely gone) and using an anti-fungal cream to keep the fungus from coming back on your skin.

We understand that patients who don't have insurance do not want to incur an extra laboratory cost. While it is recommended, sending a piece of your nail to the lab is not mandatory. A lab examination of your nail will of course rule in or rule out an infection and based on this, whether you will need a treatment or not.

Q: Is there any pain during the laser treatment?
A: With the temperature control system on the laser, it can create a temperature hot enough to kill the fungus, but not hot enough to injure the patient or cause discomfort. There is no pain during the procedure and no anesthetic is needed.

Q: When can cure be ascertained?
A: Knowing if the treatment works takes time. One cannot expect to see an immediate response. Clinical cure is 100% clearance. Halux (big toe) nails grow 1-2 mm/month.Average male halux nail is 22 mm. If 75% of the nail is involved, it can take 6-12 months to grow out. If only 20% of nail is involved, it can take 5 months to grow out. Mycological cure – confirms the eradication of the fungus through mycological assay in the laboratory.

Clinical Cure – The Increase in Clear Nail


Q: How long after laser treatment may I return to normal activities?
A: You may return to normal activities immediately following your treatment. There is no lingering discomfort or down time.

Q: Can the fungus come back after a successful treatment?
A: Yes, it can come back after a successful treatment. Toenail fungus starts with athlete's foot so it is important to prevent it in the future with good foot hygiene and an antifungal cream on the skin once a week. This decreases the chances of getting the infection back in the nails. If for any reason you become re-infected with fungus or need additional treatments at any point in the future, you will enjoy a 70% off (from our published retail price, not from the special price) lifetime guarantee for future re-treatment! This is a unique offering that is backed by the strength of our Stanford Medical Center-tested laser technology.

Q: Is a second treatment ever necessary
A: Like any infection, occasionally the fungus can be resistant to treatment, whether by laser or oral medicines. You can also be completely treated and get re-infected by the fungus. If for any reason you become re-infected with fungus or need additional treatments at any point in the future, you will enjoy a 70% off (from our published retail price, not from the special price) lifetime guarantee for future re-treatment! This is a unique offering that is backed by the strength of our Stanford Medical Center-tested laser technology.

Q: Is laser treatment of toenail fungus covered by my insurance?
A: Because it is a new technology, laser treatment of toenail fungus is not covered by health insurance. Laboratory testing of the toenail is generally covered by most insurance plans. Follow-up treatment of the skin with anti-fungal cream is usually with an over-the-counter product.

Q: How much does the laser treatment itself cost?
A: We usually prefer to treat all 10 toenails to make sure there is no living fungus remaining. The fee for the first treatment of the 10 nails is $1000. This does not include lab testing (which is usually covered by insurance). If for any reason you become re-infected with fungus or need additional treatments at any point in the future, you will enjoy a 70% off (from our published retail price, not from the special price) lifetime guarantee for future re-treatment! This is a unique offering that is backed by the strength of our Stanford Medical Center-tested laser technology.

Q: Why is a laboratory confirmation of a fungal infection important?
A: While half of nail abnormalities is caused by a fungal infection, the other 50% is caused by other etiologies such as psoriasis of the nails, lichen planus, low serum albumin, trauma, bacterial infections, etc. Some of you have been treated with oral and/or topical medications for years and years without success. If there was no laboratory confirmation of a fungus, one cannot say that the anti-fungal medications failed. If the nail abnormality is not caused by a fungus, no anti-fungal treatment will succeed. For a nail abnormality that has pestered you for so many years, in some cases as much as 25 years, a laboratory diagnosis is a must and just makes sense. Otherwise, both patient and physician will be shooting in the dark.

Q: How much is the fungus test?
A: We found a laboratory that will charge a self-pay patient $121 for a fungal culture. This is the cheapest fee we found which goes down to $60 if the doctor pays the laboratory for the patient. Why charging the doctor for the patient is cheaper - I don't know. Culturing a specimen will allow the fungus to grow in a medium. This is the ultimate test for presence of infection.

Q: What do I expect with my first appointment
A: If you never had any laboratory confirmation of a nail fungus infection, I will strongly advise that we take a nail clipping and underside scraping of your abnormal nail to be sent to a laboratory. If you agree to this, you can wait for three days for the result, then schedule an appointment for the laser treatment once the report confirms the presence of a fungus. You can also have your laser treatment done on the same day pending the lab result. Some people who chose to be treated pending the lab result usually come from far away cities. They have been clinically diagnosed by other doctors and do not want to make an extra trip for the treatment.

If you do not want a laboratory diagnosis for whatever reason, and wish to go ahead with the laser treatment during your first appointment, then we will perform the laser treatment.

*Please bring a pair of open toe slippers or flip flops when you come in for treatment.