RealSelf Q&A with Dr. Buka

Author: Dr. Bobby Buka

Q: Which is the best face skin tightening treatments nowadays?

A: Ultherapy

There are a dizzying number of “face skin tightening” treatments available to dermatologists and plastic surgeons these days. It can be a challenge even for us to pick the right device for our patients. Its important to focus on reproducible data points and consistent before/after photography. And don’t forget the mechanism of action has to make plain sense. That is, tell me you can reshape deep collagen with powdered ostrich feathers or snail secretions and I just don’t get it!

For my office, we selected Ultherapy. One of the limitations to my other laser devices is depth – even my most powerful carbon dioxide laser only penetrates 3-4mm into the skin. That’s great for acne scarring, but if I’m trying to tighten underlying connective tissue and subcutaneous fat, I need to get lower. Ultherapy uses target ultrasound to bypass the skin’s surface and direct energy right where I need it – 4-7mm where tightening begins from the “ground up”. By creating micro-injury to septal fat, overlying skin retraction occurs naturally over the next 1-3 months.

It’s a very interesting process to watch unfold and my patients have never been more satisfied. Best of all, there’s a bunch of additional applications I believe are coming in the pipeline.

Q:  I am on Accutane. What can I expect?

A:  Expect great results with mild side effects.

Isotretinoin (Accutane) is perhaps the most powerful medication we have in our armamentarium against acne. Not only does it greatly decrease active acne lesions, it has a remarkable durability, usually resulting in clearance for years after the end of a therapeutic course. Your medication course is typically weight-based and can last 4-6 months depending upon how many milligrams you take each day. Side effects are dose-dependent, meaning the more Accutane, the more side effects. Dryness is far-and-away the most common side effect we notice in patients receiving Accutane. It’s not a good or bad sign and won’t affect the overall length of your course; it’s just one of the common side effects experienced on this medication. Very severe acne sufferers may notice a temporary worsening of their acne prior to overall improvement, but usually it’s a steady improvement from Day 1. In my experience, the most notable results are seen during months #2-3.

Q:  I have a birthmark which is lighter than my surrounding skin. Is there any treatment for that?

A:  There’s no easy fix, but there are options available!

Lighter or “hypopigmented” birthmarks can range from collections of pigment high in the dermis (rather than spread throughout) to vascular insufficiencies that result in a harmless patch of whitish skin. Nearly all hypopigmented birthmarks are benign, however, there are a few that may be a indication of an inherited syndrome (like ash leaf spots in Tuberous sclerosis).

Admittedly, no matter what the cause, repigmenting skin is far more challenging for dermatologists than lightening darker birth marks which can be a challenge in its own right. If the hypopigmented birthmark is small enough, we can excise it and bring normally colored skin on either side together to even the skins appearance.

Acne scarring is unfortunately a separate topic altogether. Accutane may make scars appear redder, but typically won’t improve them. It just works on active acne lesions. But don’t despair! There are presently amazing treatments for acne scarring, with laser and chemical peels being the most routinely used among them.

Q:  CO2 laser on entire face. Lots of redness and blisters almost 3 weeks post?

A:  This powerful laser treatment can produce amazing results, but requires more downtime and recovery.

CO2 Laser is perhaps the most powerful laser we have in our dermatologic armamentarium. The laser’s target is water and, since we’re 70% water, that a lot of target to hone in on. The laser’s frequency (how fast the energy oscillates) is 10,600 nanometers which also means it penetrates deeper than any of our other lasers, up to 4mm in depth (!), well into the dermis. The result is powerful collagen reshaping and rejuvenation, but also the potential for a lot of “down time” when the face looks weepy, inflamed, and swollen. If we turn the CO2 energy down, we can get modest results with redness that lasts a few hours. If we turn the energy up, we can see weeks to months of redness but with remarkable improvement in scars and signs of photoaging. So depending upon the settings your doctor used, redness 3 weeks out is very expected. And severe enough redness may even result in pin-point bleeding. Generally, that’s all part of the healing process.

It is critical to keep the treated areas of the face out of the sun. If you must have some sun exposure, please use sunscreen. My favorite is Elta SPF 30. Moisturize 5 times daily with something thick and ceramide-based. My favorite is FAB’s Ultra Repair Cream. Petroleum-based emollients are OK but can occlude pores and your skin needs to breathe while it heals! I’m glad you’re using a gentle cleanser – that’s key. I like the FAB Gentle Cleanser. It’s common sense, but I’ll say it anyway – no smoking, healthy eating as your body heals. It’s more important now than ever. Recently, I’ve begun to recommend over-the-counter biafine and bromelein oral supplements to our patients post-CO2. This seems to expedite healing in my experience.

The only part of your account that I would certainly call in to your treating physician is the “very visible blisters underneath the eyes.” This can be due to trauma as discussed above, to be sure, but it can also represent viral and bacterial infection and requires evaluation by a medical professional.